Pamantasan ng Lunsod ng Maynila College of Nursing NURSING CARE PLAN Patients Name: ED Age: 71 y/o Diagnosis: Pleural Effusion

2o PTB VS Pneumonia COPD in Acute Exacerbation CUES DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTION Ospital ng Sampaloc RATIONALE EVALUATION

Subjective: Nahihirapan ako huminga. as verbalized by the patient. Objective Cues: y RR: 23 cpm y Ineffective cough y Use of accessory muscles while breathing y Labored breathing y Diminished breath sounds upon auscultation y Weakness

Ineffective airway clearance r/t accumulation of mucus secretion in the bronchi

Lower respriratory tract infection Multiplication of pathogens Release of endotoxins Damage of bronchial mucous membrane Inflammatory response Accumulation of exudates Production of mucus Accumulation of mucus secretion in bronchi Ineffective airway clearance

Within 3 hours of nursing interventions, the patient will demonstrate behaviors to improve and maintain clear airway AEB: y Decrease in RR from 23 to 20 cpm y Able to expectorate mucus secretions y Show minimal use of accessory muscles during respirations y Exhibit unlabored breathing

1. Establish rapport with the client and clients significant others. 2. Monitor clients vital signs especially RR.

3. Monitor rate, depth and effort of respirations and quality of breath sounds. 4. Identify amount, color, consistency of mucus secretion.

5. Assist in deep breathing exercises.

6. Explain and teach the patient how to

1. To gain trust and The goal was cooperation of partially met. the client. After 3 hours, the patient have demonstrated 2. Changes in vital few behaviors to improve and signs indicate maintain clear progress and airway AEB: basis for the next nursing interventions. y Maluwagluwag naman 3. Promotes basis ang paghinga for evaluation of ko, hindi na patients ako condition and masyadong respiratory nahihirapan pattern. huminga as verbalized by 4. To determine the patient. proper management for y RR of 24cpm clearing the airway. y Ineffective cough 5. Promotes oxygenation y Minimal use before controlled of accessory coughing. muscles while breathing 6. Enhance patient coughing y Unlabored

y Restlessnes s

y Manifest more audible breath sounds upon ausculatation y Display absence of weakness y Show decrease in restlessness

perform several cough techniques.

techniques and enables the patient to determine cough technique that provides maximal effort and minimal exertion 7. To liquefy mucus secretion for effective expectoration 8. Promotes lung expansion and decreases lung exertion. 9. To treat respiratory tract infection 10. To relax airway muscles and increase air flow to the lungs 11. Provides O2 requirements of the system.

breathing y More audible breath sounds upon auscultation y Reduced weakness y Decreased restlessness

7. Encourage increase in oral fluid intake if not contraindicated.

8. Position the patient in semi or high fowlers position 9. Administer cefuroxime 750 mg TIV q8 as per doctors order 10. Administer salbutamol (Combivent) 1neb q6. 11. Administer O2 inhalation 2-3 L/min via nasal cannula as per doctors order