Nurs|ng Care |an

Assessment D|agnos|s Inference |ann|ng Intervent|on kat|ona|e Lva|uat|on

Sub[ect|ve
1he paLlenL
verballzed
ag ubo ko
may
lumalabas
na plema
na may
konLlng
dugo"


Cb[ect|ve
Murmurs
heard upon
ausculLaLlo
n on Lhe
rlghL lobe


lneffecLlve
alrway
clearance
relaLed Lo
reLalned
secreLlons
secondary
Lo bacLerlal
lnfecLlon as
evldenced
by murmurs
heard upon
ausculLaLlon

8acLerlal
lnfecLlon of
Lhe
resplraLory
sysLem


lnflammaLor
y response


8eLalned
secreLlons ln
Lhe
resplraLory
LracL

AfLer 4hours
of nurslng
lnLervenLlon
Lhe paLlenL
wlll be able
Lo have a
paLenL
alrway
Lhrough Lhe
moblllzaLlon
of secreLlons
as
evldenced
by
producLlve
cough
Check vlLal
slgns

MonlLor
resplraLlons
and breaLh
sounds





Lncourage
deep
breaLhlng and
explraLory
maneuvers
(Laklng a
deep breaLh
and
coughlng)

lncrease
fluld lnLake








oslLlon
paLlenL
approprlaLely




erform
chesL
physloLherap
y


8asellne
daLa

May
lndlcaLe
resplraLory
dlsLress or
accumulaLl
on of
secreLlons


1o
maxlmlze
efforL







hydraLlon
can help
llquefy
vlscous
secreLlons
And
lmprove
secreLlon
clearance

1o prevenL
vomlLlng
and
asplraLlon
ln Lhe
lungs

1o help
paLlenL
breaLhe
freely and
Lo geL
more
AfLer 4
hours of
nurslng
lnLervenLl
on Lhe
paLlenL
was able
Lo have an
effecLlve
alrway



Lncourage
opporLunlLles
for resL

AuscaulLaLe
breaLh
sounds
oxygen ln
Lhe body

revenLs
faLlgue


1 o
ascerLaln
sLaLus and
noLe
progress