ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Ineffective airway Within 30 mins. of Independent:

clearance related to handling the patient, he After 30 mins. of
“Nabudlayan ako mag increased production of will:  Assess airway  To maintain nursing intervention,
ginhawa.” As verbalized bronchial secretions patency. adequate airway goals are partially
by the patient. secondary to fluid shift  Establish an patency. met, with RR=22cpm,
to extravascular effective and with no signs of
compartment. respiratory  Encouraged deep  Promote chest nasal flaring, rapid
Objective: pattern. breathing expansion. shallow breathing
(Inspiration and exercises. and cyanotic nail
 Nasal Flaring expiration that does not  Normal beds but still with O2
provide adequate respiration as  Position patient  Positioning helps support.
 Slight cyanotic ventilation.) evidenced by in semi- or high- maximize lung
nail beds absence of Fowler’s position. expansion.
dyspnea and
 rapid shallow adventitious  Suction  To clear the airway
breathing breath sounds. secretions

 Tachypnea, RR of  Demonstrate Collaborative:

28cpm appropriate
coping behaviors.  Administer O2 at  Provides adequate
1-2 Lpm via nasal oxygen supply.
 Independence cannula.
from oxygen
support.  Obtained blood  Assess the condition
specimen for of the client.
 Absence of nasal Arterial Blood
flaring and cyanotic Gas study.
nail beds.