Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective airway Short term: Independent Short term:

clearance related to
“nahihirapan siyang After 8 hours of nursing - Monitor respiration and - To indicate if there is After 8 hours of nursing
presence of secretion
huminga kapag walang intervention, the patient will breath sounds. intervention, the patient
respiratory distress
oxygen.” as verbalized be able to: and/or further was able to
by the patients wife accumulation of maintain/improve airway
Inference : -Maintain or improve airway clearance patency.
clearance or patency. secretion.
Inhales microorganisms - Maintain adequate - To loosen secretion
Objective: Long term: hydration
Transmitted to alveoli Long term:
-RR: 23 CPM After 3 days of nursing - Elevated head of the bed
Less function intervention the patient will - To open or maintain After 3 days of nursing
in fowlers position.
- Difficulty of breathing (impaired gas be able to: open airway in at rest. intervention the patient
exchange) was able to demonstrate
- Wheezing upon -Demonstrate behaviors to
auscultation - Encourage adequate rest behaviors to improve/
Mucus production improve or maintain clear - To limit fatigue
periods. maintain clear airway
-Productive cough airway.
Phagocyte produce
-Inability to expectorate Collaborative
phlegm Accumulation of
exudates in alveoli - Assist with procedures - To maintain clear and
-with oxygen therapy such as administering open airway.
Mucus secretion Oxygen.

Ineffective airway - Administer - To promote

clearance bronchodilator pharmacologic
medications as regimen.
prescribed.