ASSESSMENT P#1: S: O:> v/s: BPPR RR T– > (+) persistent productive cough, unable to expectorate phlegm, if he can it is characterized s yellowish in color, very viscous

> (+) nasal discharges noted, whitish in color > (+) crackles on both lung fields upon auscultation > not pale nor cyanotic > capillary refill at 1 sec > nail beds re pinkish > (-) use of accessory muscle

EXPLANATION OF THE PROBLEM BPN inflammation in the alveoli producing exudates or excessive secretion stays in t he tracheobronchial tree interferes with the diffusion of oxygen and carbon dioxide > Impaired Gas Exchange related to altered oxygen supply. > Ineffective Airway Clearance related to accumulation of secretion in the tracheobronchial tree

OBJECTIVE STO: >After 8 hours of nursing intervention the patient will be able to increase fluid intake from 4-5 to 6-8 glasses of water per day. LTO: >After 2-3 days of nursing intervention the patient will be able to: * manifest clear breath sound * expectorate phlegm easily

INTEVENTION Dx: > Auscultate lungs for presence of abnormal breath sounds.

RATIONALE

EVALUATION

>In order to assess the lungs if there is a crackling sound because secretions in the lungs can cause difficulty in breathing. >Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lungs. > In order to know the indication of infection in the respiratory. > Lowers diaphragm, promoting chest

>Assess vital signs esp. rate/dept of respirations and chest movement.

> Assess characteristic of phlegm/sputum. Tx: > Assist the patient in semi-fowler position and change

when breathing > with ongoing oxygen administration at 1 -2 LPM via nasal cannula > with symmetrical lung expansion > patient only drinks 4 -5 g lasses of water per day A: Impaired Gas Exchange related to altered oxygen supply. Ineffective Airway Clearance related to accumulation of secretion in the tracheobronchial tree. Risk for infection related to accumulation of secretion in the tracheobronchial tree.

> Risk for infection related to accumulation of secretion in the tracheobronchial

position frequently.

expansion, mobilization and expectoration. > It loosens secretion along the airway, in order for the patient to expectorate phlegm easily. > By increasing fluid intake, it helps to liquefy secretion for easier expectoration of phlegm. > Oxygen therapy is the best way of supplementing oxygen to the body. > By increasing fluid intake, it helps to liquefy secretions for easier expectoration of phlegm. > DBE helps

> Provide back tapping.

> Offer a glass of water every now and then.

> Regulate oxygen administration to 12 LPM as ordered. Ed: > Instruct patient to increase fluid intake.

> Demonstrate to

the patient the proper way of coughing exercise and DBE. > Advise patient to continuous changing position from side to side while lying down.

maximum expansion of the lungs or smaller airways. > It helps in mobilization of secretion in order to expectorate it easily and to avoid dryness of secretions.