ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective Short term goal: INDEPENDENT: Goal half met,

“nahihirapan ako airway- clearance
huminga” as related to After 5 hours of 1. Positioning of the 1. To provide patient, After 4 hours of
verbalized by the excessive mucus nursing patient with head unobstructed airway, nursing intervention,
patient production intervention, on mid line with maximum lung patient expectorated
patient will slight flexion excursion secretions and RR
OBJECTIVE: expectorate 2. Auscultating 2. To monitor for the decreased from 26bpm
RR: 26bpm secretions patient’s chest presence of abnormal to 19-20bpm
effectively and RR breath sounds
-Nasal flaring will decrease from
-DOB 26bpm to normal 3. Provide chest and 3. Chest physiotherapy
-Wheezes on both range of 16 to back clapping with facilitates the
lung fields 20bpm vibration loosening of secretions
-Non-productive
Cough COLLABORATIVE:
-Dyspnea 4. Administered 4. Aids in mobilization
-use of accessory mucolytics as of secretion
muscle indicated 5. Fluids are required to
5. Provided replace insensible loss
supplemental fluids and aids in
mobilization of
secretions
6. Monitored chest x- 6. Follows progress and
ray, ABG and pulse effects of disease
oximetry results process
NAME OF ROUTE/FREQ/ MECHANISM INDICATION CONTRAINDICATION ADVERSE NURSING
DRUG DOSAGE OF ACTION EFFECT RESPONSIBILITIES

Brand Name: Route: Unknown. Relief of mild Contraindicated in Hematologic: If there is fever,
Tempra P.O. Thought to pain or fever patients Hemolytic assess patient’s
produce withhypersensitivity to anemia, fever or pain: type of
GenericName: Frequency: analgesia by thedrug neutropenia, pain, location,
Paracetamol q4h-q6h blocking leukopenia, intensity, duration,
generation of pancytopenia temperature, and
Classification: Dosage: pain impulses, Hepatic: diaphoresis.
Non-narcotic 500 mg probably by in liver damage,
analgesics and hibiting jaundice Tell patient not touse
anti-pyretics prostaglandin Metabolic: for marked fever
synthesis in the hypoglycemia (higher than39.5 º C).
CNS or the Skin: Fever persisting
synthesis or rash, urticaria longer than 3 days,
action of other or recurrent
substances that fever unless directed
sensitize pain by prescriber.
receptors to
mechanical or Avoid giving patient
chemical aspirin or aspirin-like
stimulation. It is analgesics because it
thought to inhibits platelet
relieve fever by aggregation.
central action in
the Teach client warning
hypothalamic signs that needs
 heat-regulating immediate attention
center. of the physician.

Evaluate
therapeutic effects

PREPARED BY:
JHENELYN RAMOS