ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Nabudlayan ako mag ginhawa. As verbalized by the patient.

Ineffective airway clearance related to increased production of bronchial secretions secondary to fluid shift to extravascular compartment. (Inspiration and expiration that does not provide adequate ventilation.)

Within 30 mins. of handling the patient, he will:  Establish an effective respiratory pattern.  Normal respiration as evidenced by absence of dyspnea and adventitious breath sounds.  Demonstrate appropriate coping behaviors.
 Independence

Independent:  Assess airway patency.  To maintain adequate airway patency.  Promote chest expansion. After 30 mins. of nursing intervention, goals are partially met, with RR=22cpm, and with no signs of nasal flaring, rapid shallow breathing and cyanotic nail beds but still with O2 support.

Objective:  Nasal Flaring  Slight cyanotic nail beds  rapid shallow breathing  Tachypnea, RR of 28cpm

 Encouraged deep breathing exercises.  Position patient in semi- or highFowler s position.  Suction secretions Collaborative:  Administer O2 at 1-2 Lpm via nasal cannula.  Obtained blood specimen for Arterial Blood Gas study.

 Positioning helps maximize lung expansion.  To clear the airway

 Provides adequate oxygen supply.

from oxygen support.

 Absence of nasal flaring and cyanotic nail beds.

 Assess the condition

of the client.