Sie sind auf Seite 1von 1

Cues

Nursing Diagnosis
Ineffective airway clearance related to increased sputum production.

Rationale
Allergens

Expected Outcome
After 3 days of nursing interventions, the patient will demonstrate behaviors to improve airway clearance.

Nursing Intervention
Independent: Auscultate breath sounds. Note Adventitious breath sounds like wheezes, crackles and rhonchi. Elevate head of the bed, have patient lean on over bed table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Encourage or assist with abdominal or pursed lip breathing exercises. Assist with measures to improve effectiveness of cough effort. Increased fluid Intake

Rationale
Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the bed facilitates respiratory function by use of gravity. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Provides patient with some means to cope with or control dyspnea and reduce air tapping. Coughing is most effective in an upright position after chest percussion. Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm.

Evaluation
After 3 days of nursing interventions goal was met the patient was able to demonstrate behaviors to improve airway clearance.

Subjective: Nabudlayan mag ginhawa akon bata as verbalized by the mother. Objective:

Histamine release

Bronchospasm

Edema of bronchial mucosa

Abnormal Breath sounds. V/S taken as follows: T: 36.3 P: 101 R: 63


Increased bronchial Secretions

Dependent: Administer bronchodilators as prescribed. >Administer Humidified oxygen and IV fluid

To reduce the viscosity of secretions.

>To replace fluid loss, mobilization of secretions.

Gases trapped in alveoli and reduced ventilation Collaborative: Coughing, shortness of breath and wheezing >Chest X-Ray, ABG, and pulse oximetry readings. >Follows progress and effects of disease process. and therapeutic regimen. And facilitates necessary alterations in therapy.

Source:

Nursing Care Plans Marilyn E. Doenges

Melvin D. Martinez BSN 3

Patient: Gadian, John Mark

Das könnte Ihnen auch gefallen