Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Ineffective Airway Independent:

Clearance related to (Irritant StG: StG:
retained and inhalation) Within 2hrs of • Assess In • Proper After Within
Edema of nasal Nursing semi positioning 2hrs of
mucous, signed by Intervention, the fowlers helps in Nursing
clients mother said Inflammatory airway potency position draining Intervention,
that he had runny Response will be maintained, secretions the airway
nose and cough for secretions will be potency was
two days. readily be
expectorated and • Encourage • Will maintained,
Inceresed there will be sign Breathing promote secretions
production of of reduction in exercise lung was be
secretion congestion. expansion readily
• Vital expectorated
LtG: signed and there was
monitored • For baseline be sign of
Airway Within 4 hours of reduction in
constriction and record comparison
nursing congestion.
intervention, the Dependent: Prescribed
patient will be medication as LtG:
maintained airway • Administer bronchodilators
Dyspnea
potency, secretions Prescribed Helps in aiding After 4 hours
will be readily medication effective airway of nursing
expectorated and clearance intervention,
there will be no the patient
sign of congestion. wasl be
maintained
• Hydration airway
can help potency,
 • Encourage liquefy secretions
the patient viscous was be
to drink 8 secretions readily
glasses of and improve expectorated
water per secretion and there will
day clearance be no sign of
congestion.
• Provide • Nebulization
supplemen helps in
tal liquefying
humidifica secretions
tion via for better
Nebulizer and faster
expectoratin
g the
secretions.
Collaborative:

• Perform • To identify
chest X- causative
ray factors.