Cues Family Objective Nursing Rationale Resources Method of Expected

Nursing Interventions Family Outcome

Problem Contact

S: Ineffective Short term: 1. Monitor -Indicative of Time, effort Home Short term:
airway After 8 respiration respiratory and Visit After 8
O: clearance hours of and breath distress and/or participation hours of
-Fast related to nursing sounds, noting accumulation of the family nursing
Breathing pneumonia intervention, rate and of secretions, and intervention,
-Increase as the client sounds. monitor students. the client
and change evidenced will 2.Evaluate effectiveness. will be able
in rate and by fast demonstrate: client’s cough/ - To determine to
depth of breathing, gag reflex and the ability to expectorate
respiration increase and -Decrease in swallowing protect airway. by means of
-RR: 49cpm changes in rate and ability. -To loosen the tapping by
-Dyspnea rate and depth of 3. Perform mucus the mother
depth of respiration Chest tapping. secretions for and decrease
respiration -Absence of 4. Assess in easy in rate
and cough. Dyspnea the depth of expectorations. respirations
respiration -Tachypnea Long term:
Long term: and chest shallow After 2
After 2 movement. respiration and consecutive
consecutive 5. Assist with asymmetric home visits,
visits, the monitor chest the client
client will be effects of movement are will be from
free from nebulizer frequently Dypnea,
Dyspnea and treatments and present changes in
changes in other because of rate
rate respiratory discomfort of respirations
respirations physiotherapy. moving chest and lessen
wall and or cough.
fluids.
-Facilitates
liquefaction
and removal of
secretions.