Assessment

With unproductive cough

With wheezes and crackles
auscultated on left lower
lung field.
Presence of clear watery
discharge from her nose
Restlessness
Irritability
Vital Signs
BP 112/71 mmHg
Pulse 88/min
O2Sat 95%
Temp. 98.7

Diagnosis
Ineffective
airway
clearance
related
decrease
ability to
expel the
excessive
mucus
produced.

Plan

Intervention

Assist patient to
change position
every 30
minutes

To mobilize
secretions

Elevate head of
bed and align
head in the
middle
Provide health
teachings
regarding
effective
coughing and
deep breathing
exercise.
Encourage to
increase fluid
intake.
Encourage
steam inhalation
Administer
meds as ordered

To facilitate
breathing
To expel the
mucous
To liquefy
secretions

Evaluation
Short
Term: After 34 hours of
nursing
interventions,
the patients
respiration shall
have improved
and difficulty
of breathing
shall have been
relieved.

To moisten
secretions and
alleviate
congestion
Long Term:
To reduce
bronchospasm
and mobilize
secretion

After 3 4
days of
nursing
interventions
, the patient
will have
been able to
maintain a
patent
airway.