Assessment Nursing diagnosis Scientific explanation

Planning Intervention Scientific rationale Evaluation

April 26, 20102:00PM

Subjective:

Stated:

“nahihirapan akong huminga” as verbalized by the patient

Objectives:

Inability to expectorate phlegm

Behavioral changes: restlessness

Adventitious sound (crackles)

DOB

RR of 27 bpm

Ineffective airway clearance related to retained mucus secretion as evidenced by unproductive cough

inhales microorganism

transmitted to alveoli

less function(impaired

gas exchange)

mucus production (inflammatory

reaction)

Phagocyte produce

Accumulation of exudates in alveoli

⬆ mucus secretion

ineffective airway clearance

Reference: medical surgical nursing: 11th

edition volume 1 Brunner and

Discharge outcome:

After 1 week of nursing intervention the client will be able to:Demonstrate

behaviors to improve or maintain clear airway such as following pharmacologic regimen and doing pursed lip technique

Demonstrate absence of mucus secretion with breath sounds clear respiratory noiseless

Short term out come:

After 2 days of nursing intervention the client will be able to:Maintain airway

clearance/patency

independent:

Monitor respiration and breath sound

Encourage hydration at least 8 glasses of water/day

Position head appropriate for condition such as fowler’s position

Encourage adequate rest period

Collaborative

Assist with procedure such as administering O2

Administer medication such as bronco dilators

Assist with

To indicative of respiratory distress and/or accumulation of secretion

To loosen secretion

To open or maintain open airway in at rest or compromised individual

To limit fatigue

To maintain clear open airway

To promote pharmacologic regimen

February 24, 2010 12:00pm

Discharge outcome:

Partially achieve

After 1 weeks of nursing intervention the client can be able to:

Demonstrate behaviors to improve or maintain clear airway such as following pharmacologic regimen and doing pursed lip technique

Short term outcome:

Achieve

After 2 days of nursing intervention the client can be able to:

Suddarath Maintain proper fluid volume

Clear secretion readily

monitor hypothermia therapy use of respiratory device and treatment

A various therapies may acquire/maintain adequate airways improve respiratory function and gas exchange

Maintain airway clearance/patency

Maintain proper fluid volume

Clear secretion readily