ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective: Ineffective After 2 hours • Monitor RR, • To After 2 hours of
“Nahihirapan Airway of nursing taking note of the establish nursing
akong Clearance related interventions, the depth and rate, baseline data intervention, goal
huminga dahil sa to client’s BP, PR and monitor was not met as
plema”, as presence of respiration will •Auscultate lung changes evidenced by an
verbalized by the Secretions improve and fields, noting • To increase in the
client. secondary to difficulty of presence of determine depth and rate of
Community – breathing will be adventitious possible respirations due
Objective: acquired relieved. breath sounds bronchospas to an increase in
• productive pneumonia • Elevate head of m or difficulty of
cough – bed to high obstruction breathing.
sputum is fowler’s
thick and • To
brownish in facilitate
color • Provide health breathing and
• crackles teachings lung
• DOB regarding expansion
• Deep coughing and
breathing deep breathing • To
exercise. facilitate in
• irritability
the expulsion
• Encourage of mucus
client to increase
fluid intake to
about 2000 mL • To liquefy
secretions
• Administer
medications such
as expectorants
• To reduce
as ordered
bronchospas
m and
mobilize
secretions