Assessment Diagnosis Planning Intervention Evaluation

S Ineffective airway STG INC SHORT TERM

clearance R/T After 2 hrs of nursing  Assess patient GOAL
“Medyo nahihirapan difficulty to expel intervention, pt will: Level of
din ako makahinga ng excessive secretions consciousness GOAL MET
maayos dahil sa AMB  Demonstrate a  Assess V/S After 2 hrs of NI,
nahihirapan akong clear and patent  Auscultate and goal met AEB:
mailabas yung plema airway clearance document
ko” as verbalized by  Intermittent  Expels sputum breath sounds Coughing out
the pt coughing with ease  Assess the secretions w/ ease
 Mild DOB color, and effective that
O  Passage of consistency showed clear
thick grayish and amount of patent airway
INSPECTION: sputum secretions clearance
 Intermittent  Amount: 2 ml  Increase fluid
coughing of expelled intake
 Mild DOB  Provide
 Passage of thick VS percussion
grayish sputum and vibration
 Amount: 2 ml of  Pr: 70 bpm to loosen
expelled  Rr: 24bpm secretions
sputum  BP: 120/80  Teach and
 Body Temp: instruct pt on
PALPATION: 37 c deep
 Presence of breathing
Tactile  O2 Sat: 90 % exercises
fremitus  Teach and
AUSCULTATION Chest X-Ray shows : encourage pt
 mild to do splinting
wheezing right lower lobe while
heard upon consolidation coughing
auscultation  Elevate HOB
or place in a
semi-fowler’s
VS position
 Reposition the
 Pr: 83 bpm pt q2
 Rr: 27 bpm  Provide warm
 BP: 120/80 environment
 Body Temp:  Instruct the
37 c patient to
avoid cold
 O2 Sat: 90 % fluids and
avoid
Chest X-Ray shows : contacting a pt
w/ recent
right lower lobe infections or
consolidation respi
infections
 Provide oral
hygiene after
 coughing out
secretions and
after
suctioning

DNC
 Administer
humidified O2
1 LPM via
nasal cannula
as ordered
 Administer
bronchodilator
and suction
every 2 to 4
hrs as ordered
 Provide
postural
drainage as
ordered
before meals
 Administer
other
medications as
ordered

CNC
 Refer to lab
for sputum
culture and
sensitivity