Assessment Diagnosis Plannin Intervention Rationale Evaluation

g
Ineffective Short term: Independent: Fully met:
Subjective:
airway If the paient
“Nahihirapan clearance After 8hours maintain patient
ako sa pag hinga” of *Monitor and keep *precipitators airway,
As verbalized by
related to environmental of respiratory
Nursing secretions will
the patient increased intervention, pollution to a reaction that be mobilized,
production secretions minimum can trigger or airway patency
of will be exacerbate will be maintain
Objective: respiratory mobilized, onset of acute free of secretions
*Rapid breathing/ airway episode and clear lung
secretions
Tachypnea patency will sound.
*Cough with be maintain *Assess respiratory *assesses the Partially met:
yellow sputum free of patterns, including condition of
If the patient
production secretions rate, depth, and the client
secretions will
* Have and clear lung effort, and assess
be mobilized but
adventitious sound the vital sign
not maintain
sound patient airway
(Crackles) *assist the patient *Elevation of
Goal unmet:
PR. 89Bpm Long term: to elevate head of the bed
If the secretion
RR. 36Cpm After 1week the bed for about facilities
of the patient
of nursing 30 degrees and ask respiratory
will not be
interventions, the client to function by
mobilized,
the patient assume dorsal use of gravity.
airway patency
will maintain recumbent It also
will not be
a patent position. decreases
maintain free of
airway and pressure on the
secretions and
get result test abdomen when
not maintain
for Covid 19. assuming the
patient airway
position.
*Assist patient to *To mobalized
Change position secretions
every 30 mins.

*Educate patient *To promote

deep breathing chest
exercise expansion

Educative:
*To give right
*Educate patient
knowledge to
about medication,
the patient
indication, dosage,
side effect of the
medicine
Treatment:
*Giving by *medication
Bronchodilators/ that make
antibiotic breathing
medication based easier by
on doctors order relaxing the
muscles in the
lungs and
widening the
airways
*Give a *To make
supplement oxygen breathing
as ordered (via easier
nasal cannula)

Dependent

Collaborative:

*Collaborative
*Obtain blood
with other
specimen for atrial
health care
blood gas study
provider to
and covid test as
know if they
indicated
have
abnormalities