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Assessment Nursing Scientific Goal of Care Nursing Rationale Evaluation

Diagnosis Rationale Intervention

Cues: P:Ineffective Irritation to Short Term: Independent: Short Term:


airaway nasal mucosa
clearance After 5 minutes • Elevate • To After 5 minutes
Subjective: E: related to of nursing head of promote of nursing
“ Masakit ang inflamed nasal Activation of ntervention the the bed/ proper ntervention the
dibdib at batok mucosa inflammatory patient will be Change airway. patient was able
ko, S/Sx: response able to have position. to have effective
nahihirapan as manifeted effective airway • Monitor • Assess airway
akong by: clearance as vital any clearance as
huminga”, as • Nasal Swelling of manifested by: signs signs manifested by:
verbalized by discharg tissue lining including andf
the patient. e • (-)Nasal respirato symptom • (-)Nasal
• Shortnes discharg ry s of discharge
Objective: s of Interference e rhytyhm respirato • Lessen
• Nasal breath with normal • Lessen and note ry Shortness
discharg • Irritabilit drainage from Shortnes for any distress of breath
e y sinusess and s of respirato • Decrease
• Shortne • Fatigue mucuosal breath ry Irritability
ss of membrane • Decrease distress • Reduce
breath Irritabilit • Encourag • Allow Fatigue
• Irritabilit y e deep lung
y Enlargement • Reduce breathin expansio Long Term:
• Fatigue of normal Fatigue g n to
polyps compens After 8-10
Long Term: ate for minutes of of
the nursing
Increase After 8-10 decrease interventions
blockage of minutes of of d oxygen the client have
Nasal airway nursing level. maintain airway
interventions • Keep patency as
the client will environ • To evidence by:
Increase maintain ment decrease
airway airway patency allergen d • (-)Nasal
resistance
as evidence by: free irritants. discharge

• (-)Nasal
discharg • (-)
Ineffective e Dependent: Shortness
airway of breath
clearance. • (-) • (-)
Shortnes Irritability
s of • (-)Fatigue
Reference: breath
• (-)
Medical- Irritabilit
Surgical y
Nursing • (-)Fatigu
pp.1098 e

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