ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

- Subjective: Ineffective After 8 hours -Assist patient to -Elevation of After 8 hours

-”nahihirapan airway of nursing assume position the head of the of nursing
ako huminga” as clearance intervention comfort bed facilitates intervention
verbalized by the related to the client will e.g ,elevate the respiratory the client will
patient increased demonstrate head of the bed function of use demonstrate
mucus behaviors to encourage patient of the gravity behaviors to
secretions. improve to lean on -Provides improve airway
airway overbed table or patient with clearance
clearance sit on the edge of some means to Cough
Objective: Cough the road cope or control effectively and
-Dyspnea effectively dyspnea and expectorate
-Productive cough and -Encourage or reduce air mucus.
-V/s taken as expectorate assist with purse trapping
follows mucus. lips breathing -Humidity helps
T:36.5 exercise reduce
PR:63 viscosity of
RR:25 -Encourage or secretions,
BP:110/80 assist with pursed facilitating
lips breathing expectoration
exercises. and may
-Provide reduce and
supplemental may reduce or
humidification like prevent the
nebulizer formation of
thick mucus
plugs in
bronchioles
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