Nursing Diagnosis: Ineffective airway clearance r/t symptoms of disease process aeb diminished breath sounds.

Nursing Diagnoses
1. Ineffective airway clearance r/t symptoms of disease process aeb diminished lung sounds. 2. Deficient fluid volume r/t decreased fluid intake aeb increased body temperature. 3.Activity intolerance r/t fatigue aeb patient stating I'm too tired to do anything. 4. Fatigue r/t symptoms of disease process aeb pt taking multiple naps during the day. 5. Acute pain r/t joint inflammation aeb patient needing pain medication. 6. Impaired comfort r/t symptoms of disease process aeb pt feeling restless.

Expected outcomes
1. Patient will state pain relief after 30 minutes of oral Tylenol administration. . !atient will have a productive cough before discharge. ". !atient will drin# $%% ml of fluid every hour. &. 'ital signs will remain in normal limits during hospital stay ()*.+,-)).$, !.%-$%% R $ -$. /! )%/.%- $")/+) 0. !atient will ambulate at least & times a day. .. !atient will show understanding of (1D/ by demonstrating bac# to the nurse after teaching.

Nursing Intervention
1. Administer Tylenol per MD order. 2. Administer expectorant per MD order. 3. Encourage fluid intake every hour. 4. Assess vital signs every 4 hours. 5. Encourage ambulation every 4 hours. 6. Teach turn, cough deep breathe before discharge. 7.Assess respirations every 4 hours. 8.Teach factors that can exacerbate symptoms before discharge.

Rationale
1. Tylenol is a non- opiod analgesic and antipyretic. If a patient is in pain, using Tylenol can help decrease pain in order to cough effectively and to ambulate. Also, Tylenol can help reduce fever which may help the pt feel well enough to ambulate. Tylenol can also be found in OTC cold and flu medications. (davis drugguide.com search tylenol) 2. An expectorant thins mucus in the respiratory tract. This allows the secretions to be coughed up more easily. Chest congestion can be lessened and airways can be cleared easier.(davis drug guide.com search expectorant) 3. Encouraging fluid intake can help think respiratory secretions. When the secretions are thinner they are easier to cough up. This also prevent mucosal drying. (Nursing Diagnosis Handbook Ackley and Ladwig pg 130)

Evaluation
1. Met. Patient stated pain relief after 30 min of Tylenol administration. 2.Met. Patient had a productive cough. 3. Unmet. Patient did not drink 100ml of fluid every hour. 4. Met. Vitals remained in normal ranges during stay. 5. Met. Patient ambulate more than 4 times a day. 6. Met. Patient demonstrated back TCDB after teaching. 7. Met. Respirations stayed between 12-16 breaths per minute, normal depth, without excessive effort and lung sounds will not be adventitious.

Nursing Diagnoses
1. Ineffective airway clearance r/t symptoms of disease process aeb diminished lung sounds. 2. Deficient fluid volume r/t decreased fluid intake aeb increased body temperature. 3.Activity intolerance r/t fatigue aeb patient stating I'm too tired to do anything. 4. Fatigue r/t symptoms of disease process aeb pt taking multiple naps during the day. 5. Acute pain r/t joint inflammation aeb patient needing pain medication. 6. Impaired comfort r/t symptoms of disease process aeb pt feeling restless.

Expected outcomes
1. Patient will state pain relief after 30 minutes of oral Tylenol administration. . !atient will have a productive cough before discharge. ". !atient will drin# $%% ml of fluid every hour. &. 'ital signs will remain in normal limits during hospital stay ()*.+,-)).$, !.%-$%% R $ -$. /! )%/.%- $")/+) 0. !atient will ambulate at least & times a day. .. !atient will show understanding of (1D/ by demonstrating bac# to the nurse after teaching.

Nursing Intervention
1. Administer Tylenol per MD order. 2. Administer expectorant per MD order. 3. Encourage fluid intake every hour. 4. Assess vital signs every 4 hours. 5. Encourage ambulation every 4 hours. 6. Teach turn, cough deep breathe before discharge. 7.Assess respirations every 4 hours. 8.Teach factors that can exacerbate symptoms before discharge.

Rationale
1. Tylenol is a non- opiod analgesic and antipyretic. If a patient is in pain, using Tylenol can help decrease pain in order to cough effectively and to ambulate. Also, Tylenol can help reduce fever which may help the pt feel well enough to ambulate. Tylenol can also be found in OTC cold and flu medications. (davis drugguide.com search tylenol) 2. An expectorant thins mucus in the respiratory tract. This allows the secretions to be coughed up more easily. Chest congestion can be lessened and airways can be cleared easier.(davis drug guide.com search expectorant) 3. Encouraging fluid intake can help think respiratory secretions. When the secretions are thinner they are easier to cough up. This also prevent mucosal drying. (Nursing Diagnosis Handbook Ackley and Ladwig pg 130)

Evaluation
1. Met. Patient stated pain relief after 30 min of Tylenol administration. 2.Met. Patient had a productive cough. 3. Unmet. Patient did not drink 100ml of fluid every hour. 4. Met. Vitals remained in normal ranges during stay. 5. Met. Patient ambulate more than 4 times a day. 6. Met. Patient demonstrated back TCDB after teaching. 7. Met. Respirations stayed between 12-16 breaths per minute, normal depth, without excessive effort and lung sounds will not be adventitious.

Nursing Diagnosis: Ineffective airway clearance r/t symptoms of disease process aeb diminished breath sounds. Nursing Diagnoses
1. Ineffective airway clearance r/t symptoms of disease process aeb diminished lung sounds. 2. Deficient fluid volume r/t decreased fluid intake aeb increased body temperature. 3.Activity intolerance r/t fatigue aeb patient stating I'm too tired to do anything. 4. Fatigue r/t symptoms of disease process aeb pt taking multiple naps during the day. 5. Acute pain r/t joint inflammation aeb patient needing pain medication. 6. Impaired comfort r/t symptoms of disease process aeb pt feeling restless.

Expected outcomes
1. Patient will state pain relief after 30 minutes of oral Tylenol administration. . !atient will have a productive cough before discharge. ". !atient will drin# $%% ml of fluid every hour. &. 'ital signs will remain in normal limits during hospital stay ()*.+,-)).$, !.%-$%% R $ -$. /! )%/.%- $")/+) 0. !atient will ambulate at least & times a day. .. !atient will show understanding of (1D/ by demonstrating bac# to the nurse after teaching.

Nursing Intervention
1. Administer Tylenol per MD order. 2. Administer expectorant per MD order. 3. Encourage fluid intake every hour. 4. Assess vital signs every 4 hours. 5. Encourage ambulation every 4 hours. 6. Teach turn, cough deep breathe before discharge. 7.Assess respirations every 4 hours. 8.Teach factors that can exacerbate symptoms before discharge.

Rationale
1. Tylenol is a non- opiod analgesic and antipyretic. If a patient is in pain, using Tylenol can help decrease pain in order to cough effectively and to ambulate. Also, Tylenol can help reduce fever which may help the pt feel well enough to ambulate. Tylenol can also be found in OTC cold and flu medications. (davis drugguide.com search tylenol) 2. An expectorant thins mucus in the respiratory tract. This allows the secretions to be coughed up more easily. Chest congestion can be lessened and airways can be cleared easier.(davis drug guide.com search expectorant) 3. Encouraging fluid intake can help think respiratory secretions. When the secretions are thinner they are easier to cough up. This also prevent mucosal drying. (Nursing Diagnosis Handbook Ackley and Ladwig pg 130)

Evaluation
1. Met. Patient stated pain relief after 30 min of Tylenol administration. 2.Met. Patient had a productive cough. 3. Unmet. Patient did not drink 100ml of fluid every hour. 4. Met. Vitals remained in normal ranges during stay. 5. Met. Patient ambulate more than 4 times a day. 6. Met. Patient demonstrated back TCDB after teaching. 7. Met. Respirations stayed between 12-16 breaths per minute, normal depth, without excessive effort and lung sounds will not be adventitious.

Outcome

Nursing Intervention
7. Respirations will stay between 12-16 breaths per minute, normal depth without excessive effort and lungs sounds will not be adventitious during their hospital stay. 8. Patient will be able to state factors that can exacerbate their condition, such as smoking and allergens before discharge.

Rationale

Evaluation

4.Vital signs can be indicative of a 8. Met. Patient was able to patient's overall health. An increase in respirations or heart rate may indicate state exacerbation factors, such as smoking and respiratory troubles. They may need something to help clear their airway. allergens before discharge. (Nursing Diagnosis Handbook Ackley and Ladwig pg129)5. Activity and ambulation should be encouraged as tolerated. Body movement can help move secretions. Moving secretions can help cough them up which can help keep the airway clear. (Nursing Diagnosis Handbook Ackley and Ladwig pg 130) 6. The patient should be taught to breathe deep and preform controlled coughing. This can help clear sputum and help decrease cough spasms. This helps the patient keep their airway clear. Controlled coughing can help make the cough more effective. 7. Monitoring the patients can monitor if the patient's airway is clear. If their airway has secretions in it, their respirations may increase. When checking the breath sounds, fine crackles may be heard if there is fluid in the airway. 8.Patients should be taught to avoid certain factors to avoid exacerabations. Smoking and allergens can cause an increase in secretions. The increase in secretions can be hard to clear. It also can cause the patient to be more likely to get other illnesses. (Nursing Diagnosis Handbook Ackley and Ladwig pg 132)

Nursing Diagnosis: Ineffective airway clearance r/t symptoms of disease process aeb diminished breath sounds.