Palomo, Axcel Dean G.

BSN 219
Cues

Analysis

Nursing
Diagnosis

Goals and
Objectives

S- the clients
mother
verbalized
dumadalas
na siyang
inuubo at
sinisipon
kasabay ng
pananakit ng
tiyan niya.

The
respiratory
system
provides gas
exchange by
means of
ventilation,
oxygen
transport and
tissue
perfusion;
helps maintain
acid-base
balance and
serve as an
immune
defense. A
patient having
ineffective
airway
clearance has
an inability to
clear
secretions or
obstructions
from the
respiratory
tract to
maintain clear
airway. If not

Ineffective
airway
clearance
related to
retained
secretions as
manifested by
productive
cough and
adventitious
breath sounds

Goal:

O- the client
has productive
cough with
yellow colored
secretions
The client has
clear
discharge on
his nose.
Presence of
crackles on
chest upon
auscultation.

Nursing
Intervention

Rationale

Evaluation

The nurse will

discuss 5 out 5
importance of
therapeutic
management

Providing
information on
client
promotes trust
and
cooperation of
the patient to
the nurse

Was the client

be able to
discuss 5 out 5
importance of
therapeutic
management?
Yes:
No:
Why:

Deep
breathing
excersise and

Was the client

be able to
expectorate

After 8 hours
of nursing
intervention
the client will
have an
effective
airway
Objectives:
After 5
minutes of
discussing the
importance of
therapeutic
management
to the clients
mother, the
clients mother
would be able
to give 5 out 5
importance of
therapeutic
management
After 10
minutes of

The nurse will

encourage the
client to
perform the

treated, this
might cause a
serious
respiratory
problem.
Nanda 11th ed,
p77-81
Lippincott:
MedicalSurgical
Nursing.

nursing
intervention,
the client
would be able
to expectorate
secretions
readily.

deep
breathing
excersise and
coughing
exercise
The nurse will
be able to give
expectorants
and
bronchodilator
s as ordered
by the
physician
The nurse will
encourage the
client to
increase fluid
intake

After 30
minutes of
nursing
intervention,
the client
would be able
to
demonstrate

The nurse will

perform and
assist the
client for
postural
drainage and
chest-physio
therapy
The nurse will
be able to
assess and
note clients
response to

coughing
exercise
promote
maximal
mucous
drainage

secretions?
Yes:
No:
Why:

Expectorants
assists in
mucous
expulsion and
bronchodilator
s promotes
easy
respiration
Hydration can
help liquify
viscous
secretions and
improve
airway
clearance
Postural
drainage and
chest-physio
therapy helps
to remove
mucous in the
bronchioles
Noting clients

Was the client

be able to
demonstrate
reduction of
congestions
with breath
sounds clear
and
respiration
noiseless?
Yes:

reduction of
congestions
with breath
sounds clear
and
respiration
noiseless

After 45
minutes of
nursing
intervention,
the client will
be able to
maintain
patent airway

treatment

The nurse will

auscultate
breath sounds
and assess air
movements

The nurse will

monitor
respiration
and breath
sounds noting
rate and
sounds
The nurse will
position head
appropriate for
age and
condition

The nurse will

elevate head
of bed or
change
clients
position every
2 hours as

response to
treatment will
help the nurse
assess for
progress
Auscultating
and assessing
air movement
ascertain
status and
note progress.
It is indicative
of respiratory
distress or
accumulation
of mucous
secretion
Positioning the
head of the
client
appropriately
maintain open
airway in at
rest or
compromised
individual
Elevating the
head of the
bed or
changing the

No:
Why:

Was the client

be able to
maintain
patent airway?
Yes:
No:
Why:

needed

The nurse will

keep clients
environment
free from
allergens

position of the
client take
advantage of
gravity
decreasing
pressure on
the diaphgram
and enhancing
drainage
of/ventilation
of different
lung segments
Keeping
clients
environment
free from
allergens will
prevent the
bodys
reaction/respo
nse from
foreign
substances
which may
contribute to
the airway
problem
Nanda 11th ed,
p77-81

Nelson G. Lacsamana Jr.

BSN 211
Drug

Classificatio
n

Paracetamol
(Tempra)

Analgesic;
Anti-Pyretic

Prozinc

Minerals

Dosage and
Preparation

Tempra Syrup
Childern 1-6
y/o:
-1
Teaspoon
PRN; Q4

Young adult
and Children:
2.5 5mL OD

Indication
Fever,
headache,
muscular
aches and
pain.
Toothaches
cold earache,
fever due to
tonsillectomy
,
inocculations
and
vaccinations.
Promotes
normal
biochemical
reactions.
Strenghtens
the immune
system,
supports
normal
growth and
development.
Helps
prevent

Contraindicati
on

Side-effects

Nursing
Responsibilitie
s
Check for
physicians
order.

Renal or
hepatic dse,
cerebrovascul
ar or
hematologic
disorders.

Skin rashes
and other
allergic
reactions

After
administering,
monitor vital
signs q30.
Specially
temparature
to note
changes
Check
physicians
order before
administering
the drug.
Asses clients
response to
the drug.
Administer
proper dosage
for the client.

growth
retardation in
children and
young adult.