Assessment of Explanation of Goals Interventions Rationale Evaluation

Nursing Dx. the Problem and

Objectives
SUBJECTIVE Ineffective airway GOAL: DIAGNOSTIC: Breath sounds are Outcome criteria for
DATA: clearance is defined >Patient will have a >Auscultate breath normally clear or LTO:
“Nagkaroon siya ng as the inability to patent airway sounds q 2 hours, have scattered fine FM
ubo tapos lagnat na clear secretions or clearance. noting for rate, crackles at bases, > The patient
pawala-wala, obstructions from depth, sounds or which can be manifested clear
nasundan ng the respiratory tract LTO: any respiratory cleared through breath sounds over
pagtatae nung to maintain a clear After 2 weeks of distress (tachypnea, deep breathing. The all lung fields and
pinainom ko ng airway. nursing stridor, crackles or presence of coarse vital signs are back
paracetamol” As Retained interventions, the wheezes) crackles during late within the normal
verbalized by the secretions create a patient will have inspiration indicates ranges.
mother. vicious cycle of lung clear breath sounds fluid in the airway;
damage in a patient over all the lung wheezing indicates PM
that is unable to fields and improved an airway >Patient
OBJECTIVE clear them. When vital signs, obstruction. Thus, manifested
DATA: an irritant is specifically the this is done in order decrease crackle
>RR 40cpm inhaled, the lung respiratory rate. to monitor if there sound upon
>Irregular, shallow, defense are any presence of auscultation and
breathes through mechanisms are set STO: crackles/crackling vital signs are
mouth in motion. An Within 24 hours of >Monitor vital sounds. partially improved.
>Uses accessory inflammatory nursing signs, specifically
muscle for response occurs, in intervention, the pulse oximetry > To obtain UM
breathing which biochemical patient will be able reading and baseline data for >Crackles/Crackling
>Unable to breathe reactions take place to: respiratory rate future comparison sound is heard upon
in supine position (including release of  Manifest less as well as to assess auscultation and did
>Auscultation water into the signs of any signs and not decreased in
reveals bilateral area), producing respiratory symptoms of sound; the vital
Crackles on lower excess mucus to distress such as respiratory distress. signs did not
lobes with catch and eliminate dyspnea and If there are any improve.
decreased breath the irritant or tachypnea secretions in the Outcome criteria for
sounds at posterior bacteria from the  Manifest an RR airway, the
area lungs. When the of normal THERAPEUTIC: respiratory rate will STO:
mucus cannot be range, 16- >Administer increase. FM
NURSING mobilized and 20cpm from 40 Salbutamol through > The patient was
DIAGNOSIS: removed, secretions cpm, with nebulization as able to expectorate
Ineffective airway are retained. normal depth prescribed by the >Salbutamol, a sputum, have
clearance related to Plugging off of the and rhythm. physician. beta2 adrenergic normal breathing
retained secretion airways may lead to agonist, causes and RR is within
at lower lung fields atelectasis,  Follow and bronchodilation and normal range. The
as evidence by pneumonia and a exhibit simple > Elevate head of vasodilation thereby patient also
difficulty breathing ventilation- deep breathing bed to 45 degrees, aiding in keeping achieved increased
perfusion mismatch. exercises or change patient’s the airway clear water intake.
Inflammation and position every 2
infections cause  Increase water hours >To relax smooth PM
damage to the intake of up to respiratory >Minimal secretions
airways with 1-2 (250 mL) musculature, expectorated,
changes to its cups per hour reduce airway breathing and RR
lining. This injury is edema and mobilize are improved. The
the beginning of a secretion. patient was not
cycle in which consistent in
airways slowly lose > Also, a way of drinking 1-2 cups
their ability to clear postural drainage per hour.
out mucus. Thus, > Ensure increased where secretions
the presence of intake of warm are accumulated for
secretions on the water of up to 1-2 better expectoration UM
lower lung fields of (250 mL) cups per >The patient was
the patient. hour not able to
Retained expectorate,
secretion in the >Demonstrate > To prevent breathing and RR
airway tract can proper way of dehydration. does not show any
impair the covering mouth sign of
ventilation of the when coughing and improvements. The
patient leading to the use of mask as patient was only
ineffective airway PPE able to drink less
clearance. As a than 1 cup
result to ineffective >To help mobilize throughout the
airway clearance, secretions and for shift.
the patient had the patient to
manifestations of expectorate larger
dyspnea and amount of sputum.
tachypnea.
Breathing comes > Hydration can
naturally and help prevent the
effortlessly to accumulation of
everyone, but there viscous secretions
are some who are and improve
incapable of >Encourage rest, secretion clearance.
keeping their limit activities to Increased water
airways clear. When level of respiratory intake also helps
there is an tolerance. flush out toxins
obstruction in the from the body.
airway, coughing
takes place which it
is the main >It can supply
mechanism for more oxygen thus
clearing it. Increase lessening the effort
in the production of of the patient when
secretions in breathing and so
conditions such as the use of
pneumonia can accessory muscles.
repress these > For infection
mechanisms. control
Pneumonia is
essentially when
fluid or pus gets >Educate patient to >It helps in
trapped in the cough out phlegm reducing fatigue
alveoli of the lungs. or secretions from the energy
instead of expended in
swallowing them coughing and
generally from
being ill
>Educate mother/
caregiver on >Phlegm consists
different airway of the bacteria
clearance causing Pneumonia.
techniques, such as By expectorating
postural drainage the phlegm,
and chest
physiotherapy >For infection
control
>Educate on proper
disposal of >Various
secretions therapies/modalities
may be required to
acquire and
>Reinforce proper maintain adequate
hand hygiene on airways and
the patient and improve respiratory
caregivers functions. This is
taught to the
mother since the
child still needs
assistance
REFERENCE LIST:
Doenges, M, et al. (2017). Nurses Pocket Guide Diagnosis. Prioritized Interventions and Rationales. 14 th edition

Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-
Book: An Evidence-Based Guide to Planning Care. Mosby

Pillitteri, A. (2014). Maternal & child health nursing: Care of the childbearing & childrearing family .