Time
7:00-3:00 am F> Ineffective airway clearance related to the disease process of Tuberculosis
DATA
Subjective findings:
-“nahihirapan akong
huminga” as verbalized
by the patient
Objective findings:
-vital signs as follows: T-
38.2C, PR- 116 bpm,
RR-30 cpm, BP- 130/80
mmHg, SPO2- 90%
-productive cough
Focus/ Nursing Dx:
(PE/S)
-Ineffective airway
clearance related to the
disease process of
Tuberculosis as
evidenced by abnormal
respiratory rate of 30
count per minute
Chart
as evidenced by abnormal respiratory rate of 30 count per minute
D> Received with an intact IVF of PNSS @ 1L x KVO with a side drip of D5W 1L
x 16 @ 500 cc level; with productive cough; “nahihirapan akong huminga”
A> Assessed VS and characteristic of respirations at least every 2 hours.
Noted chest movement; use of accessory muscles during respiration. Noted
ability to expectorate mucus and cough effectively. Administered
supplemental oxygen as prescribed. Administered prescribed TB
medications, bronchodilators, steroids, mucolytics, and antiprexial
medications. Maintained humidified oxygen as prescribed. Elevated the head
of the bed and assumed semi-fowler’s position. Instructed of the proper
ways of coughing and breathing exercises. Educated to do optimal
positioning; use of pillow or hand splints when coughing; use of abdominal
muscles for more forceful cough
R> After 2 hours of nursing intervention, the patient was able to maintain
airway patency and improve airway clearance as evidenced by normal
respiration.
GOALS/ ACTION/ NURSING RATIONALE RESPONSE &
Expected outcomes INTERVENTIONS EVALUATION
STG: within Dxtc: After __8____hr/s of
___2___hour/s of NI  Assessed the  To assist in creating NI, the patient was
the patient will be able patient’s VS and an accurate able to
to characteristic of diagnosis and Maintain airway
maintain airway respirations at least monitor patency and improved
patency and improve every 2 hours effectiveness of airway clearance as
airway clearance as medical treatment manifested by normal
manifested/evidenced  Noted chest  Use of accessory respiratory rate
by: respiratory rate movement; use of muscles of between 12-20 counts
between normal range accessory muscles respiration may per minute
of 12-20 cpm during respiration occur in response to STG: fully/partially/un
LTG: after _3__days of ineffective ventilation MET
NI the patient will be  Expectoration may
able to: expectorate  Noted ability to be difficult when
secretions without expectorate mucus secretions are very After ___8___hr/s of
assistance and identify and cough thick as a result of NI, the patient was
potential complications effectively infection which may able to expectorate
and initiate appropriate require further secretions without
actions as manifested intervention assistance and
by: normal respiration identified potential
and oxygen saturation Txc:  To help clear thick complications and
through applying proper  Performed phlegm that the initiated appropriate
way of coughing and suctioning of patient is unable to actions
breathing exercises secretions as expectorate as manifested by
 necessary  To increase the normal respiration and
 Administered oxygen level and oxygen saturation
supplemental achieve an SPO2 through applying
oxygen as value at least 94% proper way of
prescribed  A variety of coughing and
 Administered medications are breathing exercises
prescribed TB prepared to manage STG: fully/partially/un
medications, specific problems. MET
bronchodilators, Most promote
steroids, mucolytics, clearance of airway
and antiprexial secretions and may
medications reduce airway
resistance
 Increasing humidity
 Maintained of inspired air will
humidified oxygen reduce thickness of
as prescribed secretions and aid
their removal
 Head elevation and
proper positioning
 Elevated the head of help improve the
the bed and assisted expansion of the
the patient to lungs, enabling the
assume semi- patient to breathe
fowler’s position more effectively

Edx:  To help remove

 Instructed the patient secretions and to
of the proper ways of promote oxygenation
coughing and before controlled
breathing exercises coughing
 Educated the patient  The proper sitting
in optimal position and splinting
positioning; use of of the abdomen
pillow or hand splints promote effective
when coughing; use coughing by
of abdominal increasing
muscles for more abdominal pressure
forceful cough and upward
diaphragmatic
movement.
Controlled coughing
methods help
mobilize secretions
from smaller airways
to larger airways
because the
coughing is done at
varying time