ASSESSMENT Subjective: “nahihirapan ako huminga dahil sa ubo ko”, as verbalized by the patient.

Objective: >inability to cough effectively >shallow respirations >febrile >anxiety >restlessness >adventitious breath sounds >tachypnea >use of accessory muscle while breathing

DIAGNOSIS Ineffective Airway Clearance related to thick tenacious secretions and airway obstruction as manifested by shallow respiration, tachypnea and fever.

PLANNING STG: After 6 hours of nursing intervention, the cliet will be able to cough effectively and clear own secretions. LTG: After 5 days of nursing intervention, the client will maintain patency of airway and will have clear breath sounds.

INTERVENTION 1. Monitor VS every 2 hrs. 2. encourage patient to position in highFowler’s or semiFowler’s positon. 3. turn patient every 2 hrs and prn.

RATIONALE

EVALUATION

4.teach client to maintain adequate hydration by drinking at least 810 glasses of fluid/day ( if not contraindicated). 5. teach and supervise effective coughing techniques. .6. perform Chest Physical therapy.

1. to assess baseline STG: data. After 6 hours of 2.promotes maximal nursing lung function. intervention, the cliet had been able to cough effectively 3.repositioning and clear own promotes drainage secretions. of pulmonary Goal was met. secretions and enhances ventilation LTG: to decrease potential After 5 days of of atelectasis. nursing 4.to help thin intervention, the secretions. client maintained patency of airway and had clear breath sounds. Goal was met. 5.to conserve energy and to reduce airway collapse. 6.CPT techniques utilizes forces of gravity and motion to facilitate secretion removal.

7. instruct on splinting abdomen with pillow during coughing efforts. . 8..monitor airway for patency and provide artificial airways as warranted. 9. administer bronchodilators as ordered. 10. instruct client/family to notify nurse if the client is experiencing shortness of breath or air hunger. 11. instruct client/family regarding medications, effects, side effects and symptoms of adverse effects to report to nurse or physician.

7.promotes increased expiratory pressure. 8.requires if patient cannot maintain airway patency. 9. to improve ventilation and maximizes air exchange. 10. may indicate bronchial tubes are blocked with mucus, leading to hypoxia and hypoxemia. 11. promotes prompt identification of potential adverse reaction to facilitate timely intervention.

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