Assessment Diagnosis Scientific Goals/Objective Nursing Scientific Evaluation

Rationale s Intervention Rationale

Subjective: Ineffective Retained After 8 hours of Independent: After 8 hours of
“nahihirapan Airway secretion in the nursing Auscultated To ascertain nursing
akong umubo at Clearance airway tract can intervention the breath sounds status and note intervention the
ilabas yung related to retain impair the patient will progress patient has
plema pero secretion as ventilation of maintain airway Position client maintain airway
naiilalabas ko manifested by the patient patency on a semi To maintain patency
din naman pero productive fowlers position open airway
pa onti-onti” as cough with After 2 hours and decrease After 2 hours
verbalize by the yellow after nursing Elevated head diaphragm after nursing
patient secretions and intervention the of bed pressure and intervention the
crackles heard patient will increase patient has
Objective: on lung field expectorate Kept drainage to lung expectorated
Crackles heard secretions environment field secretions
on both lung readily allergen free readily
field productive To lessen
cough on with After 5 hours of Encourage deep irritants that After 5 hours of
yellow green nursing breathing and can further nursing
secretions. intervention the coughing irritate nasal intervention the
Noted wide patient reflexes airway patient
eyed and verbalize verbalized
restlessness understanding Increase fluid understanding
of cause and intake of cause and
therapeutic therapeutic
management Encourage management
regimen warm fluids Help liquefy regimen
versus cold secretions
fluids

Observed sign
for respiratory To prevent
distress further
complications
Demonstrate
purse lips and
diaphragmatic
breathing
technique

Dependent: To loosen
Give secretion for
expectorants easy
as ordered expectorations