ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway After 3 days of Independent: Goal met. After 3

“Aguy-uyek toy anak clearance related nursing  Assess airway for patency. Maintaining the airway is days of nursing
kon ti tallo nga aldaw, to ineffective interventions, the always the first priority, interventions, the
ngem haan na pulos cough patient's secretions especially in cases of trauma, patient's secretions
mairwar jay plema will be mobilized and acute neurological were mobilized and
na.” (patient’s airway will be decompensation, or cardiac airway was
mother) maintained free of arrest. maintained free of
secretions, as  Auscultate lungs for presence secretions, as
Objective: evidenced by clear of normal or adventitious evidenced by clear
 Cough lung sounds, eupnea, breath sounds, as in the lung sounds,
(nonproductive) and ability to following: eupnea, and ability
 Abnormal breath effectively cough up o Decreased or absent breath These may indicate presence to effectively cough
sounds secretions after sounds of mucus plug or other major up secretions after
(crackles) treatments and deep airway obstruction. treatments and
 Cardiac rate of breaths. o Wheezing These may indicate deep breaths.
129 bpm increasing airway resistance.
 Respiratory rate o Coarse sounds These may indicate presence
of 55 cpm of fluid along larger airways.

 Assess respirations; note Abnormality indicates

quality, rate, pattern, depth, respiratory compromise.
flaring of nostrils, dyspnea on
exertion, evidence of splinting,
use of accessory muscles, and
position for breathing.

 Assess changes in mental Increasing lethargy,

status. confusion, restlessness,
and/or irritability can be
early signs of cerebral
hypoxia.

 Assess cough for effectiveness Consider possible causes for

and productivity. ineffective cough (e.g.,
BAUTISTA, Jesther Rowen, SN IV

 Note presence of sputum;
assess quality, color, amount,
odor, and consistency.
 Assist patient in performing
coughing and breathing
maneuvers.
 Instruct patient in the
following:
o Optimal positioning (sitting
position)
o Use of pillow or hand
splints when coughing
o Use of abdominal muscles
for more forceful cough
o Use of quad and huff
techniques
o Use of incentive spirometry
o Importance of ambulation
and frequent position
changes
 Use positioning (if tolerated,
head of bed at 45 degrees;
sitting in chair, ambulation).
BAUTISTA, Jesther Rowen, SN IV
respiratory muscle fatigue,
severe bronchospasm, or
thick tenacious secretions).
This may be a result of
infection, bronchitis, chronic
smoking, or other condition.
A sign of infection is
discolored sputum (no longer
clear or white); an odor may
be present.
These improve productivity of
the cough.
Directed coughing techniques
help mobilize secretions from
smaller airways to larger
airways because the
coughing is done at varying
times. The sitting position
and splinting the abdomen
promote more effective
coughing by increasing
abdominal pressure and
upward diaphragmatic
movement.
These promote better lung
expansion and improved air
exchange.
  Encourage oral intake of fluids
within the limits of cardiac
reserve.
 Demonstrate and teach
coughing, deep breathing, and
splinting techniques.
Dependent:
 Administer medications:
o Mucolytics (e.g. Guaifenesin)
o Bronchodilators (e.g.
Albuterol)
Collaborative:
 Consult respiratory therapist
for chest physiotherapy and
nebulizer treatments as
indicated (hospital and home
care/rehabilitation
environments).
BAUTISTA, Jesther Rowen, SN IV
Increased fluid intake
reduces the viscosity of
mucus produced by the
goblet cells in the airways. It
is easier for the patient to
mobilize thinner secretions
with coughing.
Patient will understand the
rationale and appropriate
techniques to keep the
airway clear of secretions.
Relieves respiratory
difficulties by hydrolyzing
glycosaminoglycans, tending
to break down/lower the
viscosity of mucin-containing
body secretions/components,
thereby dissolving thick
mucus.
Reduces resistance in the
respiratory airway and
increases airflow to the
lungs.
Chest physiotherapy includes
the techniques of postural
drainage and chest
percussion to mobilize
secretions in smaller airways
that cannot be removed by
 coughing or suctioning.

BAUTISTA, Jesther Rowen, SN IV