Assessment Diagnosis Planning Intervention Rationale Evaluation

Independent: STO:
Subjective: Ineffective airway Short Term Goal
STO: Goal
“Nahihirapan clearance R/T
fully met.
akong huminga presence of After 1 hour of >Assessed airway -To monitor
at inuubo po ako secretions AEB nursing intervention, patency airway is always
The patient is
na may crackles on both the pt. will be able to the first priority
able to cough
kasamang lung fields cough up secretions
up secretions
madilaw na effectively >Assessed cough -To consider
effectively.
plema.” for effectiveness possible causes
Rationale of the and productivity for ineffective
LTO:
Objective: problem: LTO: cough e.g. thick
Goal partially
 RR= 26 The patient will be secretions
met.
cycles per Inhalation of able to verbalize
minute bacteria through effective airway >Monitored V/S -V/S are usually
Reasons for
 Crackles on droplet infection clearance as altered in disease
goal being
both lung characterized by: conditions
partially met:
fields; more a. absence of cough
on the left Passage through b. lessened >Auscultated -To ascertain
1. Patient was
side. lower airways secretions breath sounds. state and note
uncooperativ
 Use of c. improved breath patient’s progress
e as
accessory sounds from coarse
manifested by
muscles Inflammation of to fine >Observed for -To assess
her fatalistic
when bronchioles and signs of respiratory breathing pattern
attitude
breathing. alveoli distress(increased
towards her
 CXR rate, use of
condition.
suggests accessory
moderately muscles)
advanced Infection
PTB
 Productive Recommendati
cough yellow >Positioned -To promote ons:
phlegm patient to Semi- better lung
Increased fowlers or sitting expansion and 1. Recommend
production of position improved air for follow-up
mucus secretion exchange care.

>Encouraged to -To reduce

increase fluid viscosity of
Airway obstruction intake to at least mucus and easier
2000 ml/day mobilization of
unless secretions.
contraindicated

>Encouraged -To maximize

deep breathing effort of
exercise. mobilizing
secretions.

Dependent
>Administered -Increases the
Salbutamol NEB size of the
tracheobronchial
tree thus opening
the airway
passages.

>Administered -To help thin

Ambroxol secretions.
>Provided -To examine and
information about report changes in
the necessity of color and amount.
raising
expectorations
versus swallowing
them.