Chinese General Hospital Colleges

PARAS, SARAH JANE P.

IVB1


ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
Subjective:
As verbalized by the
client, inuubo ako,
marami akong plema.


Objective:
- (+) wheezes
- (+) crackles
- Barrel chest
- Restlessness
- Use of
accessory
muscles when
breathing
- Sticky yellow
secretions
- Productive
cough
- Dyspnea
- RR: 25cpm
- Oxygen
saturation: 87%



Ineffective airway
clearance related to
bronchoconstriction and
increased mucus
production as
manifested by:

Subjective:
As verbalized by the
client, inuubo ako,
marami akong plema.


Objective:
- (+) wheezes
- (+) crackles
- Barrel chest
- Restlessness
- Use of
accessory
muscles when
breathing
- Sticky yellow
secretions
- Productive
cough
- Dyspnea
- RR: 25cpm
- Oxygen
saturation: 87%
Irritates Goblet
cells and mucous
glands


Accumulation and
increased mucus
production



Ineffective Airway
Clearance

Short term:

After 20-30 minutes
of nursing
interventions, the
client will:

- Minimize use
of accessory
muscles
when
breathing
- Decrease RR
at least 21-23
cpm

Long Term:

After 2-4 days of
nursing interventions,
the client will:

- Absence of
use of
accessory
muscles
when
breathing
- Decrease RR
less than 20
Independent:
-Establish rapport with the
client


-Monitor vital signs
especially RR

-Teach and encourage the
use of diaphragmatic
breathing and cough
exercises



-Elevate head of bed,
place in semi-Fowlers to
high-Fowlers position

-Advised to do bronchial
tapping or chest
physiotherapy

- Increase fluid intake

- Assist in mobilization
and provide proper airway
support.



-To gain trust and
active cooperation
and participation

-To have a baseline
data

-To improve
ventilation and
mobilize secretions
without causing
breathlessness and
fatigue

-To maximize lung
expansion, sustain
open airway

-To loosen secretions
and for better
expectorations

-To liquefy secretions

- Giving assistance
may decrease the
effort in the side of
the patient, while
moving it is important
Short term:

After 30 minutes of
nursing interventions, the
client had:

- Minimized use of
accessory
muscles when
breathing
- Decreased RR at
22 cpm

Long Term:

After 2-4 days of nursing
interventions, the client
will:

- Absence of use
of accessory
muscles when
breathing
- Decreased RR at
20 cpm
- Increased oxygen
at 95%
- Maintain patency
of airway
Chinese General Hospital Colleges
PARAS, SARAH JANE P.
IVB1


cpm
- Increase
oxygen
saturation at
least 95% -
100%
- Maintain
patency of
airway





- Suction nasal or oral
secretions as indicated.



Dependent:
- Administer mucolytic,
bronchodilators as ordered
by the physician




-Administer antibiotics as
prescribed

-Nebulize every 6 hours

-Administer oxygen
to provide proper
oxygenation in order
to attain the desired
move

- Mechanically help
the patient breathe
easier. Always
observe sterile
technique

- Collaboration with
the physician in terms
of pharmacological
intervention is also
vital in providing
better outcomes.

-To prevent infections


-To liquefy secretions

-To help in breathing