NURSING DIAGNOSIS

GOAL

INTERVENTIONS

RATIONALE

EVALUATION

Ineffective airway clearance related to accumulation of secretions on the bronchial wall as evidenced by PR 136bpm, RR: 28bpm, shallow breathing, nose flaring, crackles heard upon auscultation, productive cough with copious and yellow colored sputum. Verbalized by the client, “sakit akon tutunlan.”

After 4 hours

of nursing

interventions

my client will maintain airway patency..

Independent:

ØMonitor vital signs specially Respiratory rate.

ØPosition in semi fowlers position.

ØIncrease fluid intake for 1-2 liters/day if not contraindicated.

ØPerform chest physiotherapy.

ØEncourage breathing and coughing exercises.

Dependent:

Ø Administer Paracetamol 250mg/50ml Q4H PRN for temp>37.8 as ordered.

Ø PAI with Salbutamol 1 neb q6h

Ø Administer Solmux 200mg pediatric sol 5ml

Collaborative:

>Refer to X-ray technicianfor chest x-ray.

Collaborate with medical technologies for lab exams/results.

Rationale:

· serve as baseline data.

>to maintain open airway and facilitate comfort

>Hydration is the best expectorant.

>Chest tapping loosens secretions and improve ventilation of lung segments.

> To promote lung expansion.

>Decrease temperature if there is fever.

>Dilates the bronchial walls.

>Loosens and clear mucus and phlegm from the respiratory tract for easay expectoration of secretions.

> To monitor presence of secretions and pathologic factors to avoid further complication.

Goals partially met. Client maintained patent airway buts still have occasional productive cough, RR= 22bpm.