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Richard E.

Marcella

Problem: Ineffective airway clearance


Assessment Diagnosis Planning Intervention Rationale Evaluation
S: “ Pwedng mag- Ineffective After 8 hours of Diagnostic Interventions Goal met. After 8 hours of proper
nebule? airway clearance proper nursing • Monitor vital signs. • Serves as baseline data for nursing intervention, the patient:
Nahihirapan related to intervention, the comparison to evaluate
akong huminga.” bronchoconstricti patient will: patient’s condition. a.) Verbalized understanding
on, increase the cause and therapeutic
O: sputum/ mucus a.) Verbalize management regimen.
• Wheezing upon production in understanding • Assess rate or depth of • Tachypnea, shallow b.) Identify potential
inspiration and response to the cause and respirations and chest respirations and asymmetric complications and how to
expiration respiratory therapeutic movement. chest movement are initiate appropriate preventive
• Tachypnea infection as management frequently present because or curative actions.
• Prolonged evidenced by regimen of discomfort of moving c.) Maintained patent airway.
expiration tachypnea, b.) Identify chest wall and or fluid in
• Dyspnea wheezes, and potential lungs.
dyspnea complications
• Irritable
and how to
• Restless
initiate • Auscultate lung fields, noting
• Chest appropriate
tightness areas of decreased or absent
preventive or airflow and adventitious • Crackles, rhonchi and
• Anxious curative actions sounds like crackles, wheezes are heard in
• Pallor c.)Maintain patent wheezes. response to fluid
airway. • Assess respiratory status at accumulation, thick
least every 4 hours or secretions and airway
according to established spasm.
standards. • To detect early signs of
compromise.

Treatment Interventions:

• Position head midline with


flexion appropriate for age. • To open or maintain airway
• Elevate head of the head. in at rest.
• Lowers diaphragm,
promoting chest expansion,
Richard E. Marcella

Problem: Ineffective airway clearance


aeration of lung segment,
mobilization and
• Teach and encourage the use expectoration of secretions.
of deep breathing and
coughing exercises. • To improve ventilation and
• Encourage to increase oral mobilize secretions without
fluid intake. causing breathlessness and
fatifue..

• Provide bronchodilators.
• To facilitate mobilization of
Dependent Intervention secretion that interfere
• Provide supplemental fluid oxygenation.
like IV.
• To open airway.

• Fluids are required to replace


• Administer oxygen as losses which which include
ordered. insensible loss and aid in
mobilization of secretions.
Teachings:
• Assess patient’s knowledge • To help relieve respiratory
in contributing causes, distress.
treatment plan, specific
medications and therapeutic
procedures. • To determine the extent of
• Provide information about the teaching that the mother
necessity of raising and needs.
expectorating secretions
versus swallowing them.
• Encourage or provide • To examine and report
opportunities for rest. changes in color and
Instruct SO to limit activities amount.
to level of activity tolerance.
Richard E. Marcella

Problem: Ineffective airway clearance

• Prevent or lessen fatigue.

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