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Subjective data: The mother verbalizes: “Ginahapo and bata ko.” Objective data: Fast Breathing Increase and changes in rate and depth of respiration Cough Dyspnea Nasal flaring T= 35.80C P= 96 beats/min RR= 60 cycles/min
Ineffective airway clearance related to pneumonia as evidence by fast breathing, increase and changes in rate and depth of respiration, cough, dyspnea and nasal flaring.
Ineffective airway clearance is an inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
GOALS/ EXPECTED OUTCOMES
After 8º of rendering nursing care, the goals was partially met as evidenced by: Decrease in rate and depth of respiration
Within 8º of rendering INDEPENDENT: nursing care, the patient 1. Tachypnea, 1. Assess will demonstrate: shallow respirations rate/depth of respiration and asymmetric chest and chest movement. Decrease in rate movement are and depth of frequently present respiration because of discomfort of moving chest wall Absence of and or fluid in lung. dyspnea 2. Lower diaphragm, 2. Elevate promoting chest head of bed or assist expansion, aeration of patient in a semilung segments, fowler’s position with mobilization and pillow support. expectoration of secretions. DEPENDENT: 1. Assist with/ monitor effects of nebulizer treatments and other respiratory physiotherapy.
1. Facilitates liquefaction and removal of secretions.