Patient Name: __ED.

Age: _82___ Sex: ___M____ Civil Status: ___Widow____

Physician: __Dr. Apolo__________ Room
No.___001______

NURSES NOTES
Date / Time
11/24/21 S Patient complains of cough and difficulty of
breathing
O Noted onset of productive cough with
difficulty of breathing and loss of appetite
A Inefective airway clearance related to
tracheobranchial secretions and ineffective
airway
P After 8hrs. Of nursing intervention the client
will be able to do coping mechanisms to
improve his breathing pattern when it comes
to difficulty of breathing
I > Elevated head of the bed about 30 degrees
and ask the client to assume dorsal recumbent
position.
> Encourage deep breathing exercise.
m> Monitor respiratory patterns, includiny
rate, depth and effort.
> Isolation

E After 8 hours of nursing intervention the client

will able to do coping mechanism to improve
his breathing pattern when it comes to
difficulty of breathing and able to eat again.