Cues/ Needs Nursing Diagnosis Rationale Goals and Objectives Interventions Rationale Evaluation

Short term goal: Independent:

Subjective data: Ineffective airway The airway parts of the After 1 hour of nursing  Assessed patient’s  Patient education The goal was met because
“Nahihirapan akong clearance related to respiratory system which intervention the patient will knowledge about his will vary on disease after I hour of nursing
huminga” as verbalized viscous secretions as air flows, was blocked to be able to: condition. as well as the intervention the patient
by the client. evidenced by: get from the  Know how to patient’s cognitive was able to:
 RR- 39 cpm External environment to expectorate the level.  Know how to
Objective data:  Effort in the alveoli by the secretions.  Monitored for vital signs  To gather baseline expectorate the
 RR- 38 cpm breathing excessive mucus secreted  Know the ways to data and noted secretions.
 Effort in  Use of accessory by the goblet cells. decrease the changes.  Know the ways to
breathing muscle when viscosity of the  Positioned head midline  To maintain open decrease the
 Use of breathing Ref. secretions. with flexion. airway at rest. viscosity of the
accessory  There is an Medical-Surgical  Demonstrate the  Elevated head of  To take advantage of secretions.
muscle when impairment on Book importance of bed/change position gravity decreasing  Demonstrate the
breathing chest expansion expectorating the every two hours. pressure on importance of
 There is an when the patient secretions. diaphragm. expectorating the
impairment on breathe  Encouraged deep  To maximize effort in secretions
chest  Crackles (rales) breathing and coughing mobilization of
expansion on the right lung exercises. secretions.
when the of the patient  Increase oral fluid intake  To promote  The client verbalized,
patient to at least 2000 ml/day. systematic hydration “Iinom ako ng mas
breathe and to help liquefy madaming tubig para
 Crackles (rales) secretions, madali ko mailabas
on the right  Discourage use of oil  To prevent aspiration ang plema ko.
lung of the based products around into lungs. Kailangan ko mailabas
patient nose. lahat para mas maging
 Monitor vital signs and  To assess changes maayos ang paghinga
observed for signs of and noting ko.”
respiratory distress. complications.
 Provided with information  For the patient to be
about the necessity of aware of the
expectorating secretions. importance of
expectorating
DEPENDENT: secretions.
 Given bronchodilators as  For mobilization of
ordered by doctor. secretions.