ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Ineffective INDEPENDENT: Short term:

Subjective : Airway Inhales microorganism Short term:
Clearance After 20 minutes Monitored respiration and As indication of respiratory GOAL MET
“Tuwing related to of nursing breath sound distress and/or After 20 minutes of nursing
kumakati ‘yung retained Transmitted to alveoli intervention, the accumulation of secretion. intervention, the client’s
lalamunan ko mucus client will be able Assisted to monitor airway clearance/patency
kailangan ko secretion as to maintain airway hypothermia therapy use To maintain clear open was maintained.
syang i.ubo para evidenced by Less function ( impaired clearance/patency of respiratory device and airway
mawala” light crackles gas exchange) treatment
sound during
- lung
as auscultation Mucus production Assisted with procedure To maintain clear open
verbalized such as administering O2 airway Long term:
by the Long term: if needed
patient Phagocyte produce After 8 hours of GOAL MET
nursing Facilitated manual Promote patent airway After 8 hours of nursing
intervention, the suctioning of mucus intervention, The client did
Accumulation of client will not secretion not develop respiratory
exudates in alveoli develop respiratory distress from mucus
distress from accumulation.
Increased mucus mucus
secretion accumulation DEPENDENT: To promote pharmacologic
Objective: Administered medication regimen
- Light such as bronchodilators
crackles is Ineffective airway as prescribed
heard during clearance
lung
auscultation Reference:
Medical surgical nursing:
- Mucus 11 th edition Vol. 1
secretion By: Bruner and
was noted Suddarath