Assessment Explanation of Planning Intervention Rationale Evaluation

the Problem
Subjective: Clearance of STO:  Assessed  Provides a basis STO:
“Madi nga secretions is a Within 8 hours respiratory for evaluating After 8 hours
maikkat atoy common problem of nursing status adequacy of of nursing
uyek ko, sapay in patients who intervention, ventilation intervention,
adda plemak nu experience the client will the client has
aguy uyek ak. acute have no signs no signs of
Narigat pay respiratory of respiratory respiratory
umanges” tract distress and  Maintaining distress and
infections. will have a  Assessed the airway is has a clear
Although the clear breath airway patency always the breath sounds
offending agent sounds during first priority during
Objective: is a major respiration respiration.
- Oxygen in factor, the
use via nasal degree of LTO:
 Auscultated  Decreased or
cannula at 2-3 severity of After2 days of
lungs for absent breath
liter per ineffective LTO: nursing
presence of sounds may
minute airway Within 2 days intervention,
normal or indicate
- With clearance of nursing the client was
adventitious presence of
productive depends on many intervention, able to
breath sounds mucous plug
cough other factors: the patient established a
such as or other
- Use of pulmonary host will be able to normal
decreased or major airway
accessory defenses, establish a respiratory
absent breath obstruction;
muscle noted presence of normal pattern.
sounds, Wheezing
- Shallow deep underlying respiratory
wheezing and sounds may
breathing pulmonary pattern
coarse sounds indicate
- With disease, age
increasing
crackles noted lifestyle
airway
upon habits,
resistance;
auscultation environments,
Coarse sounds
on both lung airway may indicate
fields clearance self- presence of
- With 02 management fluid along
saturation of skills, and larger
92 % time of airways.
specific  Assessed
treatment. changes in  Increasing
DIAGNOSIS: mental lethargy,
Ineffective status. confusion,
airway restlessness,
clearance and/or
related to irritability
presence of can be early
secretions in signs of
the trachea cerebral
bronchial tree hypoxia.

 Assessed
changes in  Tachycardia
vital signs may be
and related to
temperature. increased
work of
breathing.
Fever may
develop in
response to
retained
secretions or
atelectasis.
 Assessed
cough for  Consider
effectiveness possible
and causes for
productivity ineffective
cough:
respiratory
muscle
fatigue,
severe
bronchospasm,
thick
tenacious
secretions
and others.

 Positioned the
patient in
semi fowler’s  These methods
position. help maintain
adequate lung
expansion
thus
preventing
buildup of
secretions
and
atelectasis.
 Encouraged the
patient to
increase oral  To loosen
fluid intake secretions.
 Kept
environment
allergen-free  Presence may
such as dust, trigger
feather allergic
pillows, smoke response that
or pollen. may cause
further
increase in
mucus
secretion.