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Cues/Clues Nursing Interference Nursing Nursing Rationale Evaluation

Diagnosis Objective Interventions


S- “Nahihirapan Ineffective Irritant After a series of Independent: The goal is met,
ako huminga Airway (inhalation) nursing after a series of
lalo na kapag Clearance ↓ interventions, -assess/check -to have a nursing
tanghali”, as Related to inflammatory airway patency patient’s baseline data. intervention
verbalized by the secretions in the response will be respiratory rate. through
patient. bronchi ↓ maintained , and maintenance of
increase secretions will -Elevate head of - to take airway patency
O- coughing, production of be readily the bed/change advantage of and reduction in
nose flaring secretion expectorated. position every 2 gravity congestion.
↓ hours. decreasing
airway pressure on the
constriction diaphragm and
↓ enhancing
dyspnea drainage
of/ventilation to
different lung
segments.

- Keep - to help patient


environment to have a clear
allergen free airway.
according to
individual
situation such as
dust, feather
pillows, smoke.

-Encourage deep
breathing
exercise and
coughing
exercise.

-Increase fluid - to help liquefy


intake to at least secretions.
2000 ml./day.

-encourage/ -prevents/lessens
provide fatigue
opportunities for
rest; limit
activities to level
of respiratory
tolerance.

- encourage - to help
/instruct mother expectorate the
to perform chest secretion.
therapy.

Dependent:

-Administer -prescribed meds


prescribe such as
medications. bronchodilators
helps in aiding
effective airway
clearance.
-Provide -nebulization
supplemental helps in
humidification, liquefying
if needed such as secretions for
nebulizer etc. better and faster
expectorating the
secretions..