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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Airway Short term goal: > Monitor -> With secretions After 8 hours of
Clearance related respiratory in the airway, the Nursing Intervention,
“nahihirapan po to excessive After 8 hours of patterns, including respiratory rate will the Pt’s breathing
akong huminga accumulation of nursing rate, depth, and increase had no more
dahil sa sipon at secretions intervention, effort. adventitious sounds
ubo ko” as secondary to secretions will be (crackles/gargles)
verbalized by the pneumonia. mobilized , airway > Assist with > It is preferable for present when
patient. patency will be clearing the client to cough auscultated .
maintain free of secretions from up secretions.
Objective: secretions, as pharynx by Gentle suctioning The patient was able
-Rapid breathing evidenced offering tissues of the posterior to demonstrate
patient’s ability to and gentle suction pharynx may coughing and deep
-Cough with effectively cough of the oral stimulate coughing breathing exercise
yellow sputum out secretions, pharynx if and help remove every 1-2 hours
production Pt’s breathing will necessary secretions during the day.
have no more
-Diminished and adventitious
adventitious sounds present
breath sounds (crackles/gargles) > Provide postural > Chest physical
(crackles) when auscultated drainage, therapy helps
and percussion, and mobilize bronchial
-Dyspnea uncompromised vibration as secretions
respiratory rate. ordered
-VS taken as
follows: > Administer > Bronchodilators
medications such decrease airway
T- 36.7 as bronchodilators resistance
P- 89 bpm or inhaled steroids secondary to
RR- 14 cpm as ordered. bronchoconstriction
BP- 100/70mmHg