ASSESSMENT DIAGNOSIS PLANING INTERVENTION RATIONALE EVALUATION

Subjective: After 2-3 hours of Independent:  To take advantage of After 8 hours of nursing
 -“ Nurse, nahihirapan Ineffective Airway nursing  Elevate head of gravity decreasing intervention the patient:
akong huminga dahil sa Clearance related to intervention the  the bed/ change position pressure on the diaphragm
plema ko” presence of patient would be every 2 hours and prn. and enhancing drainage Maintained airway
secretions. able to: of/ventilation of different patency
Objective: lung segment
Maintain airway  Monitor v/s signs especially Demonstrated reduction
 -Productive
respiratory rate, note for  To evaluate degree of
patency of congestion with
cough respiratory distress compromise
breath sounds clear,
- Dyspne Demonstrate respirations noiseless,
 Monitor respirations and
reduction of breath sounds, noting rate  Indicatives of respiratory improve oxygen
a congestion with exchange.
and sounds distress and/or
 -Wheezing breath sounds accumulation of secretions
clear, respirations  Evaluates client’s cough or Displayed absence of
 -Coarse noiseless, improve gag reflex and swallowing  To determine ability to tachypnea, dyspnea and
Crackles oxygen exchange. ability protect own airway tachycardia

 -Irritable Display absence  Suction naso/tracheal/oral GOAL MET.

of tachypnea, prn  To clear airway when
 -Facial grimace excessive or viscous
dyspnea and
tachycardia secretions are blocking
 Lack of energy airway or client is unable
 Standby Oxygen at bedside
 Decreased to swallow or cough
performance  Insert oral airway as needed effectively
 Inability to
maintain usual  For emergency
routines
 Lethargic  Advice CPT to mother
 Vital Signs:  To maintain anatomic
position of tongue and
-BP: 110/70
 Increase fluid intake to at natural airway, especially
mmHg when tongue/ laryngeal
least 2000ml/day within
-PR: 112 bpm edema or thick secretions
cardiac tolerance
-RR: 30 cpm may block airway
-TEMP.: 39℃
 Helps on secretion of
excessive mucus
  Hydration can help
liquefy viscous secretions
Dependent: and improve secretion
Give clearance
expectorants/bronchodolators as
ordered
Aids in
reduction of
bronchospas
m and
mobilization of
secretions.