Rhea Mae V.

Valles
BSN-III
Pt. D.C. 21y/o

Assessment Diagnosis Planning Interventions Evaluation

Subjective: Ineffective After 3-4 hours Nsg. Action Rationale After 3-4 hours of
Madaming plema airway clearance of nursing 1. Teach the patient 1. Deep nursing
pag umuubo ako related to interventions, the the proper ways breathing, on interventions, the
as verbalized by ineffective client will be of coughing and the other hand, client was able to
patient. cough and able to maintain breathing. promotes maintain airway
retained airway patency. 2. Educate the oxygenation patency.
Objectives: secretions patient in the before
c cough following: controlled
c colds >Optimal coughing.
c teary eyes positioning 2. The proper
V/S taken (sitting position) sitting position
as follow: >Use of pillow and splinting
T: 36.3 or hand splints of the
P: 87 when coughing abdomen
R: 22 >Use of promote
BP: 110/60 abdominal effective
muscles for coughing by
more forceful increasing
cough abdominal
>Use of quad pressure and
and huff upward
techniques diaphragmatic
>Importance of movement.
ambulation and 3. This position
frequent position promotes
changes
3. Position the better lung
patient upright if expansion and
tolerated. improved air
Regularly check exchange.
the patients 4. Increasing
position to humidity of
prevent sliding inspired air
down in bed. will reduce
4. Maintain thickness of
humidified secretions and
oxygen as aid their
prescribed. removal.
5. Encourage 5. Fluids help
patient to minimize
increase fluid mucosal drying
intake to 3 liters and maximize
per day within ciliary action
the limits of to move
cardiac reserve secretions.
and renal 6. Most promote
function. clearance of
6. Give airway
medications as secretions and
prescribed, such may reduce
as antibiotics, airway
mucolytic resistance.
agents, 7. Chest physical
bronchodilators, therapy helps
expectorants, mobilize
noting bronchial
effectiveness secretions; it
 and side effects. should be used
7. Provide postural only when
drainage, prescribed
percussion, and because it can
vibration as cause harm if
ordered. patient has
8. Provide oral care underlying
every 4 hours. conditions
such as cardiac
disease or
increased
intracranial
pressure.
8. Oral care
freshens the
mouth after
respiratory
secretions have
been
expectorated.