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DATA

NURSING DIAGNOSIS

RATIONALE

GOALS/OBJECTIVES OF CARE

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nakukurian ak paghinga tungod tak sip-on, as verbalized by Mrs. Simbajon Nakuri pag-gawas it plema kay matig-a tak pag-ubo, as verbalized by Mrs. Simbajon Objective: Dry cough Yellow green sputum Body malaise V/S taken: T- 37 P- 73 R- 22 BP120/80

Ineffective airway clearance related to excessive, thickened mucous secretions.

Bronchitis is a respiratory disease in which the mucous membrane in the lungs' bronchial passages becomes inflamed. As the irritated membrane swells and grows thicker, it narrows or shuts off the tiny airways in the lungs, resulting in coughing spells accompanied by thick phlegm and breathlessness.

Short term: After 8 hours of nursing interventions the patient will: Demonstrate improved ventilation and adequate oxygen. No signs of respiratory distress.

Independent: Assess respiratory rate, Useful in evaluating the depth. Note use of degree or respiratory accessory muscles, distress and chronicity of pursed lip breathing, the disease process. Inability to speak. Elevate head of the Oxygen delivery may be bed, assist patient improved by upright assume position to ease position and breathing work of breathing. exercises to decrease Encourage deep slow or airway collapse, dyspnea pursed lip breathing as and work of breathing. individually tolerated or indicated. Routinely monitor skin Cyanosis may be and mucous membrane peripheral in nail beds or color. central in lips or earlobes. Duskiness and central cyanosis indicate advanced hypoxemia. Encourage expectoration of sputum; suction when indicated. Thick, tenacious, copious secretions are major source if ineffective airways. Deep suctioning may be required when cough is ineffective for expectoration of

Patient display improved ventilation and adequate oxygenation of tissues and is free from symptoms of respiratory distress.

secretions. Evaluate level of activity tolerance. During severe or acute respiratory distress, patient may be totally unable to perform basic self care activities because of hypoxemia and dyspnea. Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.

Provide calm and quiet environment.

Evaluate sleep patterns, Tachycardia, note report of dysrhythmias, and changes difficulties and whether in blood pressure can patient feels well reflect effect of systemic rested. hypoxemia on cardiac function. Monitor vital signs and cardiac rhythm. May correct or prevent worsening of hypoxia.

DATA

NURSING DIAGNOSIS
Ineffective airway clearance r/t retained bronchial secretions

RATIONALE

GOALS/OBJECTIVES OF CARE
At the end of 2 hrs, the client will be able to demonstrate behaviors to improve clear airway by expectoration of retained secretions.

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nagkukuri ak paggawas hit plema kay matig-a tak ubo, as verbalized by Mrs. Simbajon.

Objective: Dry cough Chills Yellow green sputum Body malaise V/S taken: T- 37 P- 73 R- 22 BP- 120/80

Bronchitis is a respiratory disease in which the mucous membrane in the lungs' bronchial passages becomes inflamed. As the irritated membrane swells and grows thicker, it narrow sor shuts off the tiny airways in the lungs, resulting in coughing spells accompanied by thick phlegm and breathlessness.

Independent: Establish rapportposition the patient comfortably- monitor vital signs

To facilitate cooperation as well as to gain pts trust- to promote comfort- to note any significant changes that can affect the pts conditionThese promote better lung expansion and improved air exchange - These may indicate presence of mucus plug or other major airway obstruction Abnormality indicates respiratory compromise

Elevate head of bed-

Goal partially met. The client was able to demonstrate behaviors to improve clear airway but wasnt able to expectorate retained secretions.

Auscultate lungs for presence of normal or adventitious breath sounds-

Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, and position for breathingassess cough for effectiveness and productivity Assist patient in performing coughing and breathing maneuversencourage Increase oral fluid intake

Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions).-

These improve productivity of the cough-

Increased fluid intake reduces the viscosity of mucus

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