WONG, LECERY C.

7:00AM-3:00PM ROTATION
BSN 2-I JUNE 22-JUNE 26, 2020
SAINT LOUIS HOSPITAL OF THE SACRED HEART
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 manifested
OBJECTIVE clear them. When vital signs, obstruction. Thus, decrease crackle
DATA: an irritant is inhaled, specifically the this is done in order sound upon
>RR 40cpm the lung defense respiratory rate. to monitor if there auscultation and
>Irregular, shallow, mechanisms are set are any presence of vital signs are
breathes through in motion. An STO: crackles/crackling partially improved.
mouth inflammatory Within 24 hours of >Monitor vital sounds.
>Uses accessory response occurs, in nursing signs, specifically UM
muscle for which biochemical intervention, the pulse oximetry > To obtain >Crackles/Crackling
breathing reactions take place patient will be able reading and baseline data for sound is heard upon
>Unable to breathe (including release of to: respiratory rate future comparison auscultation and did
in supine position water into the area),  Manifest less as well as to assess not decreased in
>Auscultation producing excess signs of any signs and sound; the vital
reveals bilateral mucus to catch and respiratory symptoms of signs did not
Crackles on lower eliminate the irritant distress such as respiratory distress. improve.
lobes with or bacteria from the dyspnea and If there are any Outcome criteria for
decreased breath lungs. When the tachypnea secretions in the
WONG, LECERY C. 7:00AM-3:00PM ROTATION
BSN 2-I JUNE 22-JUNE 26, 2020
SAINT LOUIS HOSPITAL OF THE SACRED HEART
sounds at posterior mucus cannot be  Manifest an RR airway, the STO:
area mobilized and of normal range, THERAPEUTIC: respiratory rate will FM
removed, secretions 16-20cpm from >Administer increase. > The patient was
NURSING are retained. 40 cpm, with Salbutamol through able to expectorate
DIAGNOSIS: Plugging off of the normal depth nebulization as sputum, have
Ineffective airway airways may lead to and rhythm. prescribed by the >Salbutamol, a normal breathing
clearance related to atelectasis, physician. beta2 adrenergic and RR is within
retained secretion at pneumonia and a  Follow and agonist, causes normal range. The
lower lung fields as ventilation-perfusion exhibit simple bronchodilation and patient also
evidence by mismatch. deep breathing > Elevate head of vasodilation thereby achieved increased
difficulty breathing Inflammation and exercises bed to 45 degrees, aiding in keeping water intake.
infections cause or change patient’s the airway clear
damage to the  Increase water position every 2 PM
airways with intake of up to hours >To relax smooth >Minimal secretions
changes to its lining. 1-2 (250 mL) respiratory expectorated,
This injury is the cups per hour musculature, reduce breathing and RR
beginning of a cycle airway edema and are improved. The
in which airways mobilize secretion. patient was not
slowly lose their consistent in
ability to clear out > Also, a way of drinking 1-2 cups
mucus. Thus, the postural drainage per hour.
presence of where secretions
secretions on the > Ensure increased are accumulated for
lower lung fields of intake of warm better expectoration UM
the patient. water of up to 1-2 >The patient was
Retained (250 mL) cups per not able to
secretion in the hour expectorate,
airway tract can > To prevent breathing and RR
impair the >Demonstrate dehydration. does not show any
ventilation of the proper way of sign of
patient leading to covering mouth improvements. The
ineffective airway when coughing and patient was only
WONG, LECERY C. 7:00AM-3:00PM ROTATION
BSN 2-I JUNE 22-JUNE 26, 2020
SAINT LOUIS HOSPITAL OF THE SACRED HEART
clearance. As a the use of mask as able to drink less
result to ineffective PPE than 1 cup
airway clearance, >To help mobilize throughout the
the patient had secretions and for shift.
manifestations of the patient to
dyspnea and expectorate larger
tachypnea. amount of sputum.
Breathing comes
naturally and > Hydration can
effortlessly to help prevent the
everyone, but there accumulation of
are some who are viscous secretions
incapable of keeping and improve
their airways clear. secretion clearance.
When there is an >Encourage rest, Increased water
obstruction in the limit activities to intake also helps
airway, coughing level of respiratory flush out toxins from
takes place which it tolerance. the body.
is the main
mechanism for
clearing it. Increase >It can supply more
in the production of oxygen thus
secretions in lessening the effort
conditions such as of the patient when
pneumonia can breathing and so
repress these the use of accessory
mechanisms. muscles.
Pneumonia is > For infection
essentially when control
fluid or pus gets
trapped in the
alveoli of the lungs. >It helps in
WONG, LECERY C. 7:00AM-3:00PM ROTATION
BSN 2-I JUNE 22-JUNE 26, 2020
SAINT LOUIS HOSPITAL OF THE SACRED HEART
>Educate patient to reducing fatigue
cough out phlegm from the energy
or secretions expended in
instead of coughing and
swallowing them generally from being
ill

>Educate mother/ >Phlegm consists of

caregiver on the bacteria causing
different airway Pneumonia. By
clearance expectorating the
techniques, such as phlegm,
postural drainage
and chest >For infection
physiotherapy control

>Educate on proper >Various

disposal of therapies/modalities
secretions may be required to
acquire and
maintain adequate
>Reinforce proper airways and
hand hygiene on the improve respiratory
patient and functions. This is
caregivers taught to the
mother since the
child still needs
assistance
WONG, LECERY C. 7:00AM-3:00PM ROTATION
BSN 2-I JUNE 22-JUNE 26, 2020
SAINT LOUIS HOSPITAL OF THE SACRED HEART
REFERENCE LIST:
Doenges, M, et al. (2017). Nurses Pocket Guide Diagnosis. Prioritized Interventions and Rationales. 14th 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.