NCP

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Vital signs monitored

and recorded.

This is for baseline

comparison.

Assisted in semifowlers position.

Proper positioning
helps in draining
secretions.

Encouraged deep
breathing exercise.

These will promote

proper lung expansion.

Administered prescribed
medications.

Prescribed meds such

as bronchodilators
helps in aiding
effective airway
clearance.

Provided supplemental
humidification via use
of nebulizer.

Nebulization helps in
liquefying secretions
for better and faster
expectorating the
secretions.

EVALUATION

Short Term Goal:

SUBJECTIVE:
" nahihirapan
nanaman kasi syang
huminga as
verbalized by the
patients mother.
OBJECTIVE:
RR- 46 cpm
DOB
Coughing
(+) use of
accessory
muscles when
breathing

Ineffective Airway
Clearance r/t
secretions in the
bronchi

After 4 hours of
nursing
intervention,
airway patency
will be
maintained,
secretions will be
readily
expectorated
and there will be
signs of
reduction in
congestion.

After 4 hours
of nursing
intervention,
the goal is
met through
maintenance
of airway
patency and
reduction in
congestion.