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Assessment Nursing Inference Planning Intervention Scientific Rationale Evaluation


Subjective: Ineffective Irritant After 8hrs of Encourage client to To liquefy secretion After 8hrs of nursing intervention
airway inhilation nursing intervention increase fluid intake the goal met, as evidenced by
‘’ Maglisod clearance the clients regular respiratory rate of 20cpm.
ko og r/t respiration will
ginhawa presence improve and
tungod sa Inflammatory Elevate the head of the
of response difficulty of bed and encourage Promotes maximal
akong ubo ‘’ secretions breathing will be inspiration, enhance
frequent position
As verbalize secondary relieved and change,deep breathing expectoration of
by the patient to Acquired effectively exercise and effective secretion to improve
Airway ventilation
pneumonia expectorate phlegm coughing

Monitor vs To establish baseline
Productive Dyspnea data

Irritability Do handwashing
before and after giving To prevent transmission
Crackles medications of microorganisms

Administer medication To help expectorate

Assessment Nursing Inference Planning Intervention Scientific Rationale Evaluation

Subjective: Disturbed Coughing is After 8hrs of Provide a quiet -Reduces stress and After 8hrs of nursing intervention
sleep the body’s nursing intervention environment and limit excess stimulation, the gaol is partially met
‘’ Dili ko pattern r/t way of the client achieve visitors promoting res
makatulog exhaustion removing optimal amount of
og tarong associated foreign sleep as evidenced -These measures
tungod sa with materilal or by rested promote maximal
akong ubo’’ -Encourage adequate inspiration, enhance
interruption mucous from appearance rest balanced with
as verbalize in usual the lungs expectoration of secretion
by the -Demonstrate or moderate activity to improve ventilation
sleep and throat.
patient pattern The two show of being
rested by increased -Facilitates healing
because of general process and natural
discomfort , classification activity intolerance
Objective: excessive of cough are Elevate the head of the
coughing productive bed and encourage -To enhance immunity
and non- frequent position
cough -to help patient sleep
productive change
Fatigue cough
-Promote nutritional
Irritability intake

-administer medication
for sleep