Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Ineffective airway clearanc Within 8 hours of nursing Assess level of Helpful in identifying Within 8 hours of nursing
Cues: e related to airway obstruc interventions, the consciousness/cognition potential for airway interventions, the patient
tion secondary to patient will be able to and ability to protect problems. was able to exhibit
trauma and tissue damage exhibit behaviors to own airway. behaviors to improve and
improve and maintain maintain airway
airway clearance. Monitor respirations and Indicative for respiratory clearance.
Objective cues: breathing sounds distress and or
-demonstrates accumulation of secretions
difficulty in
breathing Monitor vital signs To identify any alterations
in pt. v/s

Encourage deep To maximize effort GOAL MET

breathing exercises

Evaluate changes in Which may be evidence of

sleeping pattern sleep apnea

Assist patient/SO in To reduce/prevent fatigue

specific airway clearance
techniques