Cues: Subective: Nahihirapan po akong huminga as verbalized by the patient

Problem/Diagnosis: Ineffective Airway Clearance

Obective: T: PR: RR: (+)Persistent

cough (+)Wheezing (+)Dyspnea (+)Restlessnes s (+)Cyanosis

Scientific Reason: Chronic Bronchitis is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway.

Intervention: Establish rapport to the pt. and SO Assess the patient condition Monitor and record V/S Position head midline with flexion on appropriate for age/condition Elevate HOB Observe S/Sx of infections Auscultate breath sounds & assess air movt Instruct the patient to increase fluid intake Demo Demonstrate effective coughing and deep-breathing techniques. Keep back dry Turn the patient q 2 hours Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage. Administer bronchodilators if prescribed.

Rationale: To gain trust and active participation To know the condition of the pt To have a baseline data. To gain or maintain open airway To decrease pressure on the diaphragm and enhancing drainage To identify infectious process To ascertain status & note progress To help to liquefy secretions. To maximize effort To prevent further complications To prevent possible aspirations These techniques will prevent possible aspirations and prevent any untoward complications More aggressive measures to maintain airway patency.

Evaluation: Short term: The patient shall have demonstrated effective clearing of secretions.

Long term: The patient shall have maintained effective airway clearance

Cues: S: Reports of dyspnea O: The patient may manifest the manifest the ffg.: with wheezes /crackles upon auscultation on BLF increase RR above normal range presence of productive cough use of accessory muscle when breathing presence of nasal flaring and retractions

Problem/Diagnosis: Ineffective Breathing Pattern RT Retained Secretions

Scientific Reason: The presence of microorganisms in the lungs causes body to increase the secretory activity of goblet cells to get rid of the invading organism but the mechanism is not enough which allows the stasis of mucus secretion leading to ineffective breathing pattern.

Intervention: Establish rapport to the pt. and SO Assess the patient condition Monitor and record V/S especially RR Provide rest periods Place pt in semi-fowlers position Increase fluid intake Keep patient back dry Change position every 2 hours Perform CPT Place a pillow when the client is sleeping Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate Maintain a patent airway, suctioning of secretions may be done as ordered Provide respiratory support. Oxygen inhalation is provided per doctors order Administer prescribed cough suppressants and analgesics and be cautious, however,

Rationale: To gain trust and active participation To know the condition of the pt To have a baseline data. To reduce fatigue and obtain rest To have a maximum lung expansion To liquefy secretions To avoid stasis of secretions and avoid further complication To facilitate secretion movt and drainage To loosen secretion To provide adequate lung expansion while sleeping. To promote physiological ease of maximal inspiration To remove secretions that obstructs the airway To aid in relieving patient from dyspnea To promote deeper respirations and cough

Evaluation: Short term:The patient shall have improved breathing pattern.Long term: The patient shall have maintained a respiratory rate within normal limits.

because opioids may depress respirations more than desired.

Cues:

Problem/Diagnosis: Impaired Gas Exchange RT Altered Oxygen Balance

Scientific Reason:

Intervention:

Rationale:

Evaluation: