2qb

ASSESSMENT

SUBJECTIVE:
maskit lang ang
aking dibdib pg
mgubo tas pag
uubo na ako may
plema n kasama
as verbalized by
the patient.
OBJECTIVES:
Positive
wheezing in
right lower
thorax
Has a
productive
cough
Vs taken
Temp: 36.2
Pulse rate: 77
bpm
RR: 25 bpm
BP: 110/70

NURSING
DIAGNOSIS

Ineefective
airway clearance
related to
increase
productive
mucous
secretions as
manifested by
productive cough

PLANNING

Within the 8hrs

of shift the
patient will able
to demonstrate
improved
ventilation and
oxygenation of
tissues within
clients normal
limits.

INTERVENTIONS
Independent :
Evaluate the
patient vital
capacity.
Assist the patient
in a semi-fownler
position.
Emphasize
adequate rest
Encourage
adequate oral
fluid intake of
2000 ml per day.
Have a stand by
oxygen.
Dependent:
Administered
mucolytics as
prescribed by
doctors and
monitors side
effects.
Administered
bronchidilator
as
recommended

RATIONALE
To assess
respiratory
insufficiency.
To facilitates
easier breath to
the patient
It provides
comfort to the
patient.
It helps to liquefy
the secretions to
the patient.
For emergency
used.
Decrease the
munsus
viscosity.

To helps enhance
the passage of
the air to the
airway

EVALUATION

mmhg