ACTUAL NURSING MANAGEMENT

S “GALISOD KO UG GINHAWA UG GATUKAR-TUKAR LANG SIYA” as

verbalized by the patient

O  Thick viscous secretion

 use of accessory muscles

 R=32 cpm

 Restlessness

A Ineffective airway clearance related to thick viscous secretion as evidenced

by statement of difficulty in breathing.

P At the end of 1 hour of intervention, patient will be able to verbalize

improve airway clearance.

I Independent:

1.Placed patient in a moderate high back rest.

2.Encouraged patient to have a pursed lip breathing exercise.

3. Instructed patient to increase fluid intake within cardiac tolerance.

4. Chest tapping done after nebulization.

Dependent:
1.Administer medication as prescribed by the physician,

(Salbutamol) Combivent

E At the end of 1 hour interventions, patient was able to verbalized

improved airway clearance.

S “GALISOD KO UG GINHAWA UG GATUKAR-TUKAR LANG SIYA” as
verbalized by

the patient

O  Thick viscous secretion

 use of accessory muscles

 R=32 cpm

 Restlesssness
A Impaired gas exchange related to altered oxygen supply as evidenced by
dyspnea.

P At the end of 20-30 minutes of intervention, patient will be able to verbalize

improve airway clearance and achieve normal respiration rate.

I Independent:

1.Placed patient in a moderate high back rest.

2. Monitored patient level of consciousness.

3.Encouraged patient to expectorate sputum.

4. Encouraged patient to have a pursed lip breathing exercise.

5. Instructed patient to increase fluid intake within cardiac tolerance.

6. Chest tapping done after nebulization.

Dependent:
1.Administer medication as prescribed by the physician,

(Salbutamol) Combivent

E At the end of 1 hour interventions, patient was able to verbalized

improved airway clearance and improved respiration rate.

S “GASAKIT AKONG DUGHAN KUNG MAG-UBO.”as verbalized by the
patient

O  Guarding behavior

 Facial grimace

 Restlesssness

 Pain scale of 6/10

A Acute pain related to related to persistent cough as evidenced by guarding

behavior when coughing.

P At the end of1 hour intervention, patient will be able to verbalize

Relieved of pain when coughing.

I Independent:

1.Instructed patient to increase fluid intake.

2.Instructed patient not to forcefully expectorate secretion.

3.Instructed patient to deep breath before coughing.

4. Provided patient with comfort measure and relaxation technique..

E At the end of 1 hour interventions, patient was able to cough out

secretions with minimal pain.

S “GAPANLUYA JUD AKONG LAWAS” as verbalized by

the patient

O  Weak in appearance.

 Dyspnea

 Hgt-143
A Activity intolerance related to generalized weakness as evidenced by

verbal reports of weakness.

P At the end of 1 hour interventionpatient will be able to increase tolerance to

activity

I Independent:

1.Provided patient with a quiet environment and privacy.

2. assisted patient to assume comfortable position

3. Instructed watcher to provide assistance to the patient

4.Instructed patient to maintain bed rest.

5.Explained to the patient the importance of rest in treatment plan.

E At the end of 1 hour intervention, patient still complains of weakness and

hence transported to room of choice.

S No subjective cue

O 

A Risk for infection related to inadequate primary defenses.

P At the end of 1 hour intervention patient will be able to reduce risk for
infection.
I Independent:

1.Monitored Temperature.

2.Observed secretions for color,characteristic, odor of sputum.

3.Instructed watcher to wear mask

4. Instructed patient to rinse mouthwith water and spit secretions.

E At the end of 1 hour intervention patient and watcher was able to verbalize

understanding and identified intervention to reduce risk of infection.