Assessment

Subjective ³Hindi ko mailabas ung

Pathophysiology
Irritant (inhalation)

Planning
Dx Short Term Goal

Intervention

Rationale

Evaluation
Short Term Goal - After 4 hours of nursing intervention, the goal is met through maintenance of airway patency and reduction in congestion. Long Term Goal - After 2 days of nursing intervention, the goal is met through decreased in respiratory rate of 14 cylces per minute.

- Vital signs monitored - After 4 hours of Nursing intervention, airway patency will be maintained, secretions will be readily expectorated and there will be signs of reduction in congestion. Long Term Goal and recorded. - Assisted in semiFowler¶s position. - Encouraged deep breathing exercise Tx - Bedside care done - Established rapport

> for baseline comparison

ibang plegma,´ as verbalized. Objective - pale in appearance - dyspnea - uses accessory muscles when breathing - productive cough - RR=41 cycles per minute Nursing Diagnosis: -Ineffective airway clearance related to secretions in the bronchi dyspnea airway constriction increase production of secretions inflammatory response

> proper positioning helps in draining secretions

> This will promote proper lung expansion

> For Proper hygiene > For patient nurse interaction >Prescribed meds such as bronchodilators helps in aiding effective airway clearance > Nebulization helps in liquefy secretions for faster expectorating of secretions

- After two days the clients respiratory rate will be 12 ± 20 cycles per minute.

- Administered prescribed medications

- Provided supplemental humidification via use of nebulizer Ex - Encouraged client to increased fluid intake - Encouraged client to expectorate secretions

> to liquefy the secretions for better patency > to reduce congestion

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