Cues Subjective: Nakukurian gad ako pag.

ginhawa labi na kun na ubo ako, kay tungod tak plema, as verbalized the client.

Nursing Diagnosis Ineffective Airway clearance related to presence of bronchial secretions.

Rationale An inflammatory process in lung parenchyma usually associated with a mark increase in interstitial and alveoli fluid. An increase in the size and number of submucous gland in the large bronchi which increases mucous production. Alveolar exudates tend to consolidate, so it is increasingly difficult to expectorate. It is related to excessive secretions and weak cough. The inflammation and increased secretions make it difficult to maintain a patent airway.

Objectives Short-term goal: After 6 hours of nursing interventions, the patient will be able to: 1. Demonstrate effective coughing and clear breath sounds. 2. Maintain patent airway at all times. 3. Relate methods to enhance secretion removal. 4. Expectorate secretions without assistance.

Nursing Intervention Short-term: Independent: 1. Auscultated breath sounds every 1 to 4 hours.

Rationale -

Evaluation Goals partially met. The patients respiration had improved with evidence of decreased adventitious breath sound upon ausculatatio n and effective expectorati on of secretions.B ut the condition was not totally eradicated due to the presence of minimal adventitious breath sounds and bronchial secretions.

Objective: > adventitious breath sound present (Crackles) >abnormal respiratory rate (31cpm) >use of accessory muscle in breathing. >ineffective coughing.

Medical-Surgical 8th edition Vol.2 by

Short-term: Independent: 1. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway 2. Monitored obstruction. respiratory patterns, 2. With secretions including rate, depth, in the airway, and effort. the respiratory rate will 3. Positioned the client increase. to optimize 3. An upright respiration. position allows for maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which Long-term goals: crowds the lungs After 2 days of 4. Encouraged the and make more nursing client to deep breathe difficult to intervention the breathe. patient will be able and perform controlled coughing. Have the 4. This technique to: client inhale deeply, can help 1. Identify and increase sputum avoid specific hold breath for several seconds, and cough 2 clearance and factors that or 3 times with mouth decrease cough inhibit

>non productive cough. >restlessness.

Black & Hawks p. 1599 and p.1602

effective airway clearance.

open while tightening the upper abdominal muscles. Long-term: Independent: 1. Provided oral care every 4 hours using a toothbrush.

spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. Long-term: Independent: 1. The toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease. 2. Body movement helps mobilize secretions and can be a powerful means to maintain lung health.

2. Encouraged activity and ambulation as tolerated. If unable to ambulate the client, turn the client from side to side at least every 2 hours. 3. Encouraged fluid intake of up to 2500 mL per day within cardiac or renal reserve.

Collaborative: 1. Administer

3. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.

medications as indicated: a. Mucolytic agents; e.g., Acetylcysteine 200mg/sachet; 1 sachet TID

Collaborative: 1. a. Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance. b. Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.

b. Bronchodilators; e.g., Salbutamol 1 neb q6 hrs