NURSING DIAGNOSIS: Ineffective Airway Clearance r/t retained mucous secretion

DEFINING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

CHARACTERISTICS BASIS INTERVENTION
SUBJECTIVE: Bacteria are Short Term: INDEPENDENT: After 5 days of
“Dugay naman ni invading the lung After 8 hours of 1. Assess the rate, - Tachypnea, nursing
akong ubo usahay parenchyma thus nursing rhythm, and depth shallow intervention,
maghangak o dili producing interventions, the of respiration, chest respirations and the patient was
gali maglisod ko inflammatory patient will be movement, and use asymmetric chest able to display
sang ginhawa” as process, and able to maintain of accessory movement are patent airway
stated by the these responses patent airway, muscles. frequently present with clear
patient leading to filling clear breath because of breath sounds,
of the alveolar sounds, and allay discomfort of decreased
sacs with restlessness. moving chest wall secretions,
exudates leading and/or fluid in lung absence of
OBJECTIVE: to consolidation. dyspnea, and
 Productive cough The airway is 2. Auscultate lung - Decreased allay
with minimal narrowed thus fields, noting areas airflow occurs in restlessness.
amount of white wheezes or Long Term: of decreased or areas with
mucous secretion crackles is being After 5 days of absent airflow and consolidated fluid.
noted heard. nursing adventitious breath Bronchial breath
 Restless interventions, the sounds: crackles, sounds can also
 Crackles heard (Brunner and patient will be wheezes. occur in these
on both lower Suddarth’s Medical able to display consolidated
lung upon Surgical Nursing patent airway with areas.
auscultation 12th Edition) clear breath
 O2 inhalation sounds, absence
attached at 1 of dyspnea, 3. Assess the - Airway clearance
L/min via nasal decreased patient’s hydration is hindered with
cannula secretions and status inadequate
 RR – 24 cpm allay restlessness. hydration and
 O2 sat – 93% thickening of
secretions.
4. Put the patient in - Promotes lung
moderate high back expansion and
rest position. decrease
respiratory efforts

5. Maintain O2 - Increasing
inhalation via nasal humidify of
cannula inspired air will
reduce thickness
of secretions and
aid their removal

6. Administered - To inhibit the

antibiotic drugs as bacterial growth
prescribed since mucous
secretions are
good breeding site
of bacteria.
 DISCHARGE PLAN

MEDICATIONS:
Give the following prescribed medications at the right time, dose, frequency and route.

ENVIRONMENT:
Encouraged to maintain a safe home free from any hazards
Encouraged to maintain cleanliness of the house and surroundings
Encouraged to provide a well ventilated area

TREATMENT:
Encourage to have a good sleeping time and adequate nutrition
Reminded significant others to always assess patient needs
Reminded to have a follow up check-up at attending physician’s clinic one week after discharge

HEALTH TEACHINGS:
Instructed the following:
 Get vaccinated and avoid socializing with people who have a persistent cough
 Eat healthy food that contain essential nutrients
 Seek medical attention if cough has persisted
 Drink warm fluids and avoid cold fluids
 Stop smoking is very important
 Take medications regularly in very strict way

OBSERVABLE SIGNS AND SYMPTOMS:

• Coughing that lasts 3 or more weeks
• Coughing up blood
• Chest pain, or pain with breathing or coughing
• Unintentional weight loss
• Fatigue
• Fever
• Night sweats
• Chills
• Loss of appetite
DIETS:
Encouraged to follow diet prescribed by the doctor
Encouraged increased oral fluid intake
Encouraged to eat foods high in calories, foods rich in vitamin C to strengthen immune system
Encouraged to not skip meals

SPIRITUAL:
Encourage patient and family members to continue going to church and never stop having faith in God.