Patient’s Initial: Patient B.L.

Age: 3yrs old Sex: Female Chief Complaint: Dyspnea

DATE CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING EVALUATION
INTERVENTIONS

M Subjective cues: Abraham Ineffective airway After 8 hours of Independent: At the end of 8
Maslow’s clearance related to nursing hours nursing
A A. Monitored the
● “Ga ubo pa gyapon siya Hierarchy excessive mucus as intervention, the interventions,
patient’s vital signs
R ma’am” as verbalized by of need evidenced by productive patient will be able goal partially met
the watcher. cough to: R: To detect as evidenced by:
C
changes in the
H ● “Maglisod pa lang gyud P patient’s
siyag luwa sa plema Rationale: A. Demonstrate health status. A. Patient’s
H
ma’am” as verbalized by improved breathing
Ineffective airway clearance B. Positioned the
11 the watcher. Y breathing remains
refers to the inability of the patient in a
unchanged.
S client to effectively clear comfortable
● Admitted with a chief secretions or obstructions position to
2 complaint of dyspnea I B. Demonstrate
from the airway, leading to optimize airway
reduction of B. Congestion
0 O compromised oxygenation clearance.
congestion with persists with
and ventilation. It can be
2 L clear breath R: Proper continuous
Objective Cues: caused by a variety of
sounds positioning can adventitious
O factors, including
4 facilitate breath sounds
● Productive cough noted. inflammation, mucus
G optimal lung upon lung
production, and airway
After 8 hours of expansion by auscultation.
● Adventitious breath sound obstruction.
7AM I nursing reducing
noted intervention, the pressure on
C
caregiver will be the chest. C. The caregiver
Reference: Nurse’s Pocket
able to: applied chest
Guide Diagnoses, Prioritized C. Auscultated breath
physiotherapy
N Interventions, and sounds and assess
and chest
Rationales 16th Edition, pp. air movements
C. Demonstrate percussion
E 24-30 techniques to R: To ascertain whenever the
effectively clear status and patient
E
secretions note progress coughs.
D

Dependent:

D. Administered
acetylcysteine
(Fluimucil) as
prescribed by the
physician.

R: It helps
facilitate the
removal of
thick
secretions
from the
airways.

Collaborative:

E. Encouraged the
patient’s caregivers
to increase oral
fluid intake of the
 patient

R: Hydration
helps to thin
respiratory
secretions

F. Demonstrated/
assisted client/SO
in performing
specific airway
clearance
techniques such as
forced expiratory
breathing or chest
percussion

R: Thick
secretions that
are difficult to
cough up may
be loosened by
tapping
(percussing)
and vibrating
the chest.

G. Educated the
mother to tap on
the back or provide
chest
physiotherapy
after inhalation of
medication

R: Helps to
mobilize and
loosen mucus
that may have
been dislodged
from the
airway walls.
Patient’s Initial: Patient Age: 1 yr old Sex: Female Chief Complaint: Dyspnea

DATE CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING EVALUATION

INTERVENTIONS

M Subjective cues: Abraham Ineffective breathing After 8 hrs of Independent At the end of 8 hours
Maslow’s pattern related to nursing of nursing
A ● “Naay tibugol iyang a. Monitor vital
Hierarchy inflammation of lungs as interventions, the interventions, goal
plema ma’am” as signs
R of Needs evidenced by dyspnea and patient will be able partially met as
verbalized by the
cough to: R: To detect any evidenced by:
C watcher.
changes in health
H P status
Rationale: A. Establish a A. Patient’s
● “Naa pud siya’y H b. Auscultate
normal or breathing
asthma ma’am” as Inflammation can lead to lung sounds
12 Y improved remains
verbalized by the airway obstruction,
respiratory R: To check for any unchanged
watcher. S narrowing the air passages
pattern as presence or character
and impeding the flow of air
2 I evidenced by of breath sounds
in and out of the lungs. This
normal B. Adventitious
0 Objective cues: O obstruction increases the
respiratory breath sound
effort required for
● Productive cough L rate c. Note rate and is still heard
2 breathing, resulting in an
noted depth of upon lung
O irregular or inefficient
4 respirations auscultation.
● Adventitious sound breathing pattern.
G B. Demonstrate
noted Additionally, inflammation
absence of R: To check for type of
can impair the exchange of
7AM ● PR: 124 bpm I cough or breathing pattern C. The caregiver
oxygen and carbon dioxide
adventitious applied chest
● RR: 48 cpm C in the lungs, leading to
breath physiotherapy
inadequate oxygenation of d. Assist the
sounds and chest
the blood and accumulation patient in a
N percussion
of carbon dioxide. Excessive comfortable
mucus production, whenever the
position
E triggered by inflammation, After 8 hours of R: To optimize lung patient
further obstructs the nursing expansion and coughs.
E
airways and can cause interventions, the facilitate easier
D coughing, exacerbating the caregiver will be breathing.
ineffective breathing able to:
pattern.

C. Demonstrate
Reference: breathing
techniques Dependent
Nurse’s Pocket Guide
to improve
Diagnoses, Prioritized e. Administered
breathing
Interventions, and acetylcysteine
pattern of
Rationales 16th Edition (Fluimucil) as
the patient
prescribed by
the physician.

R: It helps facilitate
the removal of thick
secretions from the
airways.

Collaborative

f. Encouraged
the patient’s
caregivers to
increase oral
fluid intake of
the patient
R: Hydration helps to
thin respiratory
secretions

g. Demonstrated
/assisted
client/SO in
performing
specific airway
clearance
techniques
such as forced
expiratory
breathing or
chest
percussion

R: Thick secretions
that are difficult to
cough up may be
loosened by tapping
(percussing) and
vibrating the chest.

h. Educated the
mother to tap
on the back or
provide chest
physiotherapy
after
 inhalation of
medication

R: Helps to mobilize
and loosen mucus that
may have been
dislodged from the
airway walls.

Patient’s Initial: Patient J.B. Age: 7 yrs old Sex: Male Chief Complaint: Dyspnea
DATE CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING EVALUATION
INTERVENTIONS

M Subjective cues: Abraham Ineffective breathing After 8 hrs of Independent At the end of 8
Maslow’s pattern related to nursing hrs of nursing
A ● “Naa na gyud siyay a. Monitor vital
Hierarchy inflammation of lungs as intervention, the interventions,
asthma daan ma’am signs
R of Needs evidenced by reports of patient will be able goal partially met
sugod pag anak” as
dyspnea, cough, and to: as evidenced by:
C verbalized by the R: To detect any
respiratory rate of 38 changes in health
 H watcher P status

● “Mag lisod syag hinga H Rationale: Inflammation in A. Establish a b. Auscultate for A. Stable and
ma’am pag ubuhon the lungs can lead to normal or lung sounds normal
12 Y
siya” as verbalized by compromised airway improved oxygen
the watcher S function, impaired gas respiratory R: To check for any saturation
exchange, and inadequate pattern as presence or character levels and
2 I oxygenation. This evidenced by of breath sounds report of relief
0 Objective cues: O underscores the importance absence of and decreased
of implementing hypoxia, episodes of
2 ● Productive cough L interventions that optimize dyspnea, and c. Note rate and shortness of
noted respiratory function, tachypnea depth of breath
4 O
● Dyspnea noted promote effective breathing respirations
G patterns, and enhance the
● RR: 38 R: To check for type of
patient’s overall B. Demonstrate breathing pattern B. Auscultation
7AM I
● O2 sat: 93% oxygenation status. absence of of the
C adventitious patient’s lungs
● CR: 136 breath still revealed
d. Encouraged
sounds and adventitious
expansion and
N cough breath sounds
facilitate easier
and coughing
E breathing.
is still present.
E R: By promoting lung
D function, optimal gas
After 8 hrs of exchange
Reference: and C. The patient’s
nursing oxygenation can be caregiver
Nurse’s Pocket Guide intervention, the achieved, while demonstrated
Diagnoses, Prioritized caregiver will be improving ventilation an ability to
Interventions, and able to: and preventing perform
Rationales 16th Edition complications like airway
atelectasis. clearance
C. Demonstrate techniques
airway correctly by
e. Assisted
clearance gentle tapping
patient to learn
techniques of the back
breathing
to improve and chest
exercises
breathing percussion.
pattern of R: Assisting patients in
the patient learning breathing
exercises supports
their emotional well-
being, facilitates
recovery and
rehabilitation, and
empowers them to
take an active role in
their health.

f. Encouraged
regular rest
periods and
teach the
patient to pace
activity

R: Extra activity can

deteriorate ineffective
breathing patterns.

g. Encouraged
adequate fluid
 intake

R: By promoting
adequate fluid intake,
can support respiratory
health, alleviate
symptoms, and
improve overall lung
function.

Dependent

h. Administered
Budesonide as
ordered by the
physician

R: To reduce
inflammation in the
lungs and improve
breathing patterns.

i. Administered
oxygen therapy
as ordered

R: Increase the oxygen

levels, preventing
hypoxia and
hypoxemia.
Collaborative

j. Educated the
patient’s
caregivers on
the signs and
symptoms of
respiratory
distress and
when to seek
medical for
worsening
symptom

R: to recognize
worsening symptoms
promptly, facilitating
early intervention and
improving outcomes.

k. Demonstrated/
assisted SO in
performing
specific airway
clearance
techniques for
the patient
such as forced
expiratory
breathing or
chest
 percussion

R: Thick secretions that

are difficult to cough
up may be loosened by
tapping (percussing)
and vibrating the chest.