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NCP: INEFFECTIVE AIRWAY CLEARANCE RELATED TO RETAINED AIRWAY SECRETIONS ASSESSMENT Subjective: Hirap sya huminga kasi hindi nya mailabas yung plema nya... as verbalized by the patients spouse. Objective: Difficulty vocalizing Tachypnea Productive cough VS take as follows: BP: 130/70mmhg RR:38bpm PR:73bpm Temp:35.5C DIAGNOSIS Ineffective airway clearance related to retained airway secretions. PLANNING Short term: After 4 hours of nursing interventions, the patient will be able to expectorate/ clear secretions readily. Long term: After 3 days of nursing interventions the patient will be able to demonstrate increased gas exchange in lungs. INTERVENTIONS Establish rapport with patient and family. Assess for patients cough (color, consistency amount). INDEPENDENT: Encourage deep breathing exercises. Increase fluid intake. Assist with postural drainage. Position appropriately. Maintain adequate humidity of inspired air. DEPENDENT: Give expectorants/ bronchodilators as ordered. COLLABORATIVE: Assist with use of respiratory devices and treatments. EVALUATION Short term: After 4 hours of nursing interventions, the patient was able to expectorate/ clear secretions readily. Long term: After 3 days of nursing interventions the patient was able to demonstrate increased gas exchange in lungs.

Demonstrate/ assist in performing specific airway clearance techniques. EVALUATIVE: Proceed with health teaching with constant reinforcement in principles of care. Acknowledge and encourage good individual effort and progress.

NCP: Impaired physical mobility related to neuromuscular impairment secondary to infarct left middle cerebral artery. Assessment Nursing Diagnosis Inference Planning Nursing Intervention Independent: Objective: Right-sided body weakness Limited ability to perform gross/fine motor skills Difficulty turning Slowed movement Impaired physical mobility related to neuromuscular impairment secondary to infarct left middle cerebral artery After stroke, the nerve cells in the brain die and theres a lack of oxygen that can result in permanent disability of the patient. The pathways that transmit information in the brain are interrupted. This will lead to movement dysfunction. Short term goal: After 8 hours of nursing intervention the client will be able to participate in ADLs and desired activities. Long term goal: After 3 days of nursing interventions the client will be able to increase strength and function o affected and Assess clients condition. Monitor V/S Note behavioral responses to problems of immobility. Assist patient in repositioning self in schedule. Provide safety measure such as putting side rails up Assist pt to do passive range of motion. Involve patient in doing care and assist them to learn ways of managing To know that may restrict movement. To have a baseline data. To assess functional ability. To promote level of function. To avoid risk of fall. Rationale

BP: 130/70 mmHg PR: 73 bpm RR: 38 bpm T: 35.5C

To promote circulation and avoid contracture. To facilitate cooperation of pt.

To avoid to increase blood pressure.

compensatory body part.

problems. Restrict sodium and fluid intake, as indicated.

To limit fatigue.

To enhance clients Identify energycondition. conserving techniques for ADLs. To avoid further Dependent: complication. Administer prescribed medication Collaborative: To develop Assist with treatment individual exercise of underlying program. condition. Consult with To avoid developing physical/occupational other illness. therapies. Health teaching. Emphasize with the relative the importance of proper hygiene. Encourage do universal precaution between therapies. Instructed the relative to stay with the client more frequently. To avoid cross contamination.

To promote clients safety.

Instructed the relative to maintain low salt and low cholesterol diet. Encourage the relative to participate in rendering care to the client.

To lower clients bp To promote clients comfort.