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  • Time/Date Focus D:Data A:Action R:Response D: "Sigidas It Akon Paginubo Ngan Ginkukurian Ako

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    Kasandra Dawn Moquia Beriso
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    The patient was experiencing ineffective airway clearance as evidenced by productive cough, adventitious lung sounds, tachycardia, tachypnea, and low oxygen saturation. Interventions included positioning changes, breathing exercises, increased fluids, rest periods, and monitoring of respiration. Medications were administered via IV, nebulizer, and oxygen therapy. The patient reported feeling somewhat better with decreased cough compared to earlier, though adventitious lung sounds persisted and vital signs remained elevated.

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    The patient was experiencing ineffective airway clearance as evidenced by productive cough, adventitious lung sounds, tachycardia, tachypnea, and low oxygen saturation. Interventions included positioning changes, breathing exercises, increased fluids, rest periods, and monitoring of respiration. Medications were administered via IV, nebulizer, and oxygen therapy. The patient reported feeling somewhat better with decreased cough compared to earlier, though adventitious lung sounds persisted and vital signs remained elevated.

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    6 views1 page

    Time/Date Focus D:Data A:Action R:Response D: "Sigidas It Akon Paginubo Ngan Ginkukurian Ako

    Uploaded by

    Kasandra Dawn Moquia Beriso
    The patient was experiencing ineffective airway clearance as evidenced by productive cough, adventitious lung sounds, tachycardia, tachypnea, and low oxygen saturation. Interventions included positioning changes, breathing exercises, increased fluids, rest periods, and monitoring of respiration. Medications were administered via IV, nebulizer, and oxygen therapy. The patient reported feeling somewhat better with decreased cough compared to earlier, though adventitious lung sounds persisted and vital signs remained elevated.

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    © All Rights Reserved
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    TIME/DATE FOCUS D:DATA A:ACTION R:RESPONSE

    October 8,2020 Ineffective airway D: “Sigidas it akon paginubo ngan ginkukurian ako
    4:30 pm clearance pagginhawa kun nakiwa ako” as verbalized. With
    productive cough and presence of adventitious
    sounds, crackles and wheezes, on lung fields upon
    auscultation. Vital signs recorded as follows: PR-
    120 bpm, RR-25 cpm and O2 saturation-93%.
    A: Elevated the head of the bed and assisted into
    semi-fowler’s position. Changed position
    frequently. Validated auscultation of lung fields,
    noting areas of adventitious breath sounds such as
    crackles and wheezes. Assisted with deep-
    breathing exercises. Encourage increased fluid
    intake as tolerated. Planned and scheduled
    activities to allow optimal rest periods. Monitored
    respiration and chest movements. Started IVF with
    PNSS 1L at 20 gtts/min. Started Aminophylline.
    Tapered Hydrocortisone to g6h, Salbutamol +
    Ipratropium nebulization to q6h, and Budesonide
    nebulization to q12h. Slowly tapered O2 sideflow
    bu1 lpm until 6 lpm maintaining O2 sat >95%.
    5:30pm R: “Medyo nakaginhawa na ako hin mauropay
    yana kesa han kanina” as verbalized. Adventitious
    breath sounds, crackles and wheezes, still heard
    on both lung fields. PR-108 bpm, RR-23 cpm and
    O2 saturation-94%.
    ----------------------------------------------

    ANGELICA PARDIÑAS RTRMF-CN-SN

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