ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS S
Subjective: Ineffective Airway After 2 hours Monitor RR, To establish After 2 hours of
Nahihirapan Clearance related of nursing taking note of the baseline data nursing
akong to interventions, the depth and rate, and monitor intervention, goal
huminga dahil sa presence of clients BP, PR changes is partially met as
plema, as Secretions respiration will evidenced by an
verbalized by the secondary to improve and Elevate head of To facilitate decrease in the
client. Community difficulty of bed to high breathing and depth and rate of
acquired breathing will be fowlers lung respirations due
Objective: pneumonia relieved. expansion to decrease in
productive difficulty of
cough Provide health To facilitate in breathing.
sputum is teachings the expulsion
thick and regarding of mucus
brownish in coughing and
color deep breathing
crackles exercise. To liquefy
DOB secretions
Encourage
Deep
client to increase
breathing
fluid intake to
irritability To reduce
about 2000 mL
bronchospas
m and
Administer
mobilize
medications such
secretions
as expectorants
as ordered