URTI sample charting

S – “hindi masakit ung pagubo ko pero may plema” as verbalized by the client

O – “Restlessness; productive cough; forced cough”

A – Ineffective airway clearance related to accumulation of sputum as evidenced by productive cough

P – After 8 hours of nursing intervention client will be able to learn ways to loosen phlegm and effectively expectorate sputum.

I – instruct the client to increase fluid intake to decrease viscosity of sputum; teach client to do deep breathing exercises and proper coughing exercises to mobilize the secretions; administer antitussives as prescribed by the physician.

E – After 8 hours of nursing intervention client is able to effectively expectorate sputum and learn techniques to loosen phlegm.