Richard E. Marcella Problem: Ineffective airway clearance Assessment Diagnosis S: “ Pwedng mag- Ineffective nebule?

airway clearance Nahihirapan related to akong huminga.” bronchoconstricti on, increase O: sputum/ mucus • Wheezing upon production in inspiration and response to respiratory expiration infection as • Tachypnea evidenced by • Prolonged tachypnea, expiration wheezes, and • Dyspnea dyspnea • Irritable • Restless • Chest tightness • Anxious • Pallor Planning After 8 hours of proper nursing intervention, the patient will: a.) Verbalize understanding the cause and therapeutic management regimen b.) Identify potential complications and how to initiate appropriate preventive or curative actions c.)Maintain patent airway. Intervention Diagnostic Interventions • Monitor vital signs. Rationale • Serves as baseline data for comparison to evaluate patient’s condition. • Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of discomfort of moving chest wall and or fluid in lungs. Evaluation Goal met. After 8 hours of proper nursing intervention, the patient: a.) Verbalized understanding the cause and therapeutic management regimen. b.) Identify potential complications and how to initiate appropriate preventive or curative actions. c.) Maintained patent airway.

• Assess rate or depth of respirations and chest movement.

• Auscultate lung fields, noting areas of decreased or absent airflow and adventitious sounds like crackles, wheezes. • Assess respiratory status at least every 4 hours or according to established standards.

• Crackles, rhonchi and wheezes are heard in response to fluid accumulation, thick secretions and airway spasm. • To detect early signs of compromise.

Treatment Interventions: • Position head midline with flexion appropriate for age. • Elevate head of the head. • To open or maintain airway in at rest. • Lowers diaphragm, promoting chest expansion,

Richard E. Marcella Problem: Ineffective airway clearance • Teach and encourage the use of deep breathing and coughing exercises. • Encourage to increase oral fluid intake. • Provide bronchodilators. Dependent Intervention • Provide supplemental fluid like IV. aeration of lung segment, mobilization and expectoration of secretions. • To improve ventilation and mobilize secretions without causing breathlessness and fatifue.. • To facilitate mobilization of secretion that interfere oxygenation. • To open airway. • Fluids are required to replace losses which which include insensible loss and aid in mobilization of secretions. • To help relieve respiratory distress. • To determine the extent of teaching that the mother needs. • To examine and report changes in color and amount.

• Administer oxygen as ordered. Teachings: • Assess patient’s knowledge in contributing causes, treatment plan, specific medications and therapeutic procedures. • Provide information about the necessity of raising and expectorating secretions versus swallowing them. • Encourage or provide opportunities for rest. Instruct SO to limit activities to level of activity tolerance.

Richard E. Marcella Problem: Ineffective airway clearance • Prevent or lessen fatigue.

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