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 áneffective át is a state where Position head in Open or maintain open airway After 4 hours of nursing
͞lisud na e ginhawa kay Airway in the client is After 4 hours of accoradance to her at rest or compromise individual intervention the goal was
murag na,ay ning bara͟ Clearance unable to clear nurse-patient condition met as evidence by regular
as verbalized by the related to secretions or interaction the To take advantage of the gravity breathing rythm
patient. excessive obstructions from client will be able to Elevate head of the bed decreasing pressure on the
mucus as the respiratory maintain adequate diaphragm and enhancing


c
 manifested by tract to maintain a patent airway drainage of ventilation to
u wheezes upon dyspnea, clear airway. the different segment of the lungs
auscultation adventious ámmediate Cause
u crackles upon breath sound is The patient needs to
auscultation and changes ánflammatory Teach the client proper cough to be able to
u w/ O2 therapy in respiratory response of the coughing remove the mucus
via nasal rate and body against technique
cannula 2L/per rhythm microorganism Chest physiotherapy
min. and the Apply Chest is important in
u á
PNSS 1L @ ántermediate Percussion to the Client loosening and
20 gtts/min. Cause is an mobilizing
u myspnea ánfection from Administer antibiotics as secretions.
u RR is 26 cpm MYCOBACTERáM ordered ándications for chest
u Restless Tuberculosis physiotherapy
u Laboratory Because of áncrease the include sputum
results Weakened number of fluid being retention not
-low albumin ámmune system drunk by responsive to
level 2.73 the patient. spontaneous or
normal is 3.50-5 c directed cough,
-low hemoglobin moenges, Marilynn abnormal chest x-ray
level 123 et. al, Nurses
normal is 140- Pocket Guide 11th The patient is placed
180 edition
or good venous in the proper
-platelet 452 drainage position to drain the
normal is 150 to involved lung
100 segments
-SGPT 32.6
normal is 0.0 to An increased
31 respiratory rate
-HmL 14.6 Auscultate breath sounds leads to an increase
normal is 65 and assess air in insensible fluid
-Serum Creatine movements loss during
1.17 normal is exhalation and can
0.60 to 1.10 lead to dehydration
-Glucose 69.5
normal 70 to for mocumentation To ascertain status and note
150 coordination to other progress

Provide basis for evaluating

Monitor rate, rhythm, adequacy of ventilation
depth and effort of
respiration