F- Difficulty of breathing related to productive cough and presence mucous
production as manifested by increase respiratory rate.
D-
S: “Hirap ako uminga dahil ditto sa mga plema na to.”
O: tachypneic; labored breathing
Positioned the patient on a high back rest.
Provided o2 via nasal cannula at 4LPM inc. Advised Deep breathing exercise. Advised CBP with BRP. Side rails up for safety at all times.
Monitored clearly for signs of respiratory distress.
Free from injury. Patient can breathe comfortably with O2 support. Feb. 2, 2011
F- Ineffective airway clearance related to excessive secretions and
mechanical obstructions. ( Patient biting the ET )
Patient is biting the ET.
Presence of purulent mucous secretions per ET and oral.
Positioned patient on high fowler.
Applied improvised tongue guard. Secured ET placement with proper ET tie. Suctioned secretions per ET and oral as needed. Advised patient or watcher to call for nurse’s attention when mechanical ventilator is alarming. Secured connections of mechanical ventilator to ET with appropriate mechanical ventilator setting.
Maintain patent airway.
Patient’s watcher understands the purpose of tongue guard.