This action might not be possible to undo. Are you sure you want to continue?
sa hospital” -“1 bottle lang nauubas kong tubig sa isang araw” Objective: - Adventitious Breath Sounds (Rales) -Cough with phlegm -Pale
Nursing Diagnosis Ineffective Airway Clearance related to Secretions in the bronchi
Analysis Increased amount and viscosity of secretions and/or inability to clear secretions through the normal cough mechanism may lead to pooling of secretions in lower airways. Pooling of secretions leads to infection and inadequate gas exchange. (p229, Nettina,Manual of nursing practice)
Goal and Objectives Goal: After an 8-hour shift, the client’s secretions would be lessened. Objectives: 1. After 30 minutes, the client will be able to expel mucous by: a. Doing proper coughing technique
Evaluation Goal met.
1. The client was able to expel mucous. DEVELOPMENT AL a. Teach the client proper coughing technique. The patient needs to cough to be able to remove the mucus (p530, Smeltzer,Medicalsurgical Nursing vol. 1) Chest physiotherapy is important in loosening and mobilizing secretions. Indications for chest physiotherapy include sputum retention not responsive to spontaneous or directed cough, abnormal chest x-ray
b. Applying Chest percussion
SUPPLEMENTAL b.Apply Chest Percussion to the Client.
c. Chest Drainage
SUPPLEMENTAL c. Position the client for Postural Drainage.
findings consistent with infiltrates or deterioration in oxygentaion. (p530, Smeltzer,Medicalsurgical Nursing vol. 1) The patient is placed in the proper position to drain the involved lung segments. (p530, Smeltzer,Medicalsurgical Nursing vol. 1) For infections. (NANDA)
d. Administrat ion of drugs 2. The client will be able to maintain adequate hydration by: a. Increasing oral fluid intake
FACILITATIVE d. Administer Antibiotics as ordered
2. The client was able to maintain adequate hydration.
SUPPLEMENTAL a. Increase the number of fluid being drunk by the patient. An increased respiratory rate leads to an increase in insensible fluid loss during exhalation and can lead to dehydration. (p530, Smeltzer,Medicalsurgical Nursing vol. 1)
Efficiency The time, materials, and human resources were used economically Adequacy The numbers of interventions were sufficient.
b. Regulating intravenou
SUPPLEMENTAL b. Regulate the IV fluid as ordered.
Administration of this fluid generally causes dilution of plasma solute concentration and forces water movement into cells to reestablish intracellular and extra cellular equilibrium; cells then expand or swell. (p84,Nettina,Manual of nursing practice)
Appropriateness The interventions were suitable to the client’s situation. Acceptability The interventions, setting, and timetable were realistic to the client’s situation.