Analysis Rationale Evaluation Problem/Cues s Interventions Subjective data: Increased Goal: Goal met. amount and After the 8-hour Patient verbalized viscosity of shift the client’s “Madalas ako secretions secretions will be nahihirapan and/or inability lessened and huminga ng to clear expectorated maayos. Dati nga secretions that will 3- 4 lpm ung through the contribute to oxygen ko para normal cough effective airway makahinga ako ng mechanism clearance. maayos. Pero may lead to ngayon 2-3 pooling of Objectives: nalang para secretions in 1. Teach the 1. Expectoration is The client was masanay naman lower airways. 1. After the client how to the usual method able to expel ung baga ko ng Pooling of nursing properly for collecting a the phlegm. The mas mababang secretions intervention, expectorate sputum client also oxygen.” leads to the client will phlegm. Also, specimen. The increased her infection and be able to advise the patient is fluid intake that Objective data: inadequate gas expel the client to instructed to helps in the exchange. phlegm that increase fluid clear the nose decrease of the • Patient has contributes to intake. and throat and viscosity of the productive The client productive rinse the mouth phlegm. cough with experiences cough. to decrease blood-tinged episodes of contamination of sputum in the coughing the sputum. If morning and mechanisms for sputum is too greenish clearing the thick to sputum in the airway. A expectorate, it is afternoon. patient who necessary to • Breathing with coughs long decrease its effort enough almost viscosity by • With O2 invariably increasing water inhalation at produces. content through bedside at 2-3 Violent adequate The client was lpm via nasal coughing 2. Teach client hydration able to perform canula. causes 2. After the the different (drinking water). the different bronchial nursing types of types of Measurement: spasm, intervention, breathing breathing and Vital Signs: obstruction, the client will maneuvers 2. These coughing and further be able to and assist the maneuvers will exercises and Blood Pressure: irritation of the perform client in improve the this contributed 90/60 mmHG bronchi and coughing and performing productivity of to the Body may result in breathing coughing and the cough. improvement of Temperature: 36˚ syncope maneuvers breathing the productivity C (fainting). A that will maneuvers. of cough. Pulse Rate: 105 severe, alleviate the bpm repeated, or aggravated Respiratory Rate: uncontrolled condition. 30 cpm cough that is non-productive 3. Instruct the The client is exhausting client in the learned the and potentially 3. After the following: ways to Nursing harmful. nursing • Optimal 3. Directed alleviate the Diagnosis: intervention, positioning coughing discomfort felt Ineffective Maintaining a the client will (sitting techniques help through optimal Airway patent airway be able to position or mobilize and proper Clearance is vital to life. learn ways to high secretions from positioning, related to Coughing is the alleviate the fowler’s smaller airways using of splints excessive main difficulty felt position) to larger airways while coughing, mucus as mechanism for in breathing • Use of because the using abdominal manifested by clearing the that pillow or coughing is done muscle in positive sputum airway. contributes in hand at varying times. coughing and and abnormal However, the the splints The sitting increasing fluid respiratory rate cough may be distressing when position and intake. ineffective in cough. coughing splinting the both normal • Use of abdomen and disease abdominal promote more states muscles effective secondary to for forceful coughing by factors such as cough. increasing pain from • Increasing abdominal surgical of fluid pressure and incisions/ intake upward trauma, diaphragmatic respiratory movement. Relief muscle fatigue, of dyspnea or sometimes is neuromuscular achieved by weakness. placing the client Other at rest with the mechanisms head elevated that exist in the (high fowler’s lower position) and, in bronchioles and severe cases, by alveoli to administering The client was maintain the 4. After the 4. Maintain oxygen. These able to conserve airway include nursing planned rest positioning or gain energy the mucociliary intervention, periods. promotes better from rest period system, the client will Promote lung expansion and did not macrophages, be able to energy- and improved air show respiratory and the gain/conserve conservation exchange. distress. lymphatics. energy and techniques to Factors such as will not show the client. anesthesia and respiratory 4. Fatigue is a dehydration distress and contributing can affect difficulties in factor to function of the coughing will ineffective mucociliary be lessened. coughing. system. Likewise, The client conditions that 5. After the verbalized cause nursing 5. Instruct understanding increased intervention patient in the production of the client will various importance of secretions verbalize therapies, as therapeutic (e.g., understandin appropriate: management for pneumonia, g of • Assist with her condition. bronchitis, and therapeutic procedures chemical management • Assist with irritants) can regimen for use of 5. Patient will overtax these the respiratory understand the mechanisms. betterment of devices rationale and Ineffective her condition. and appropriate airway treatments techniques to clearance can . keep the airway be an acute patent/ (e.g., secretions. postoperative • Various recovery) or therapies/ chronic (e.g., modalities from may be cerebrovascula required to r accident acquire [CVA] or spinal adequate cord injury) airways, problem. improve Elderly respiratory patients, who function and have an gas increased exchange. incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk. Nursing Care Process Marquez, Earl Howard B. FEU-IN GROUP 109