Assessment SUBJECTIVE: Naa pa man siya plema pero dili na kayo daghan as verbalized by mother OBJECTIVES: Respiratory depth:

: deep Wheezing and crackles on both upper and lower lung fields noted upon auscultation productive cough ( whitish colored secretions in moderate amount)

Nursing Diagnosis Ineffective Airway Clearance related to retained secretions

Nursing Care Plan 1 Objectives Intervention SHORT TERM: At the end of thirty minutes of nursing intervention, the patient will be able to: 1. readily expectorate secretions. 2. exhibit no difficulty in spontaneous breathing. LONG TERM: At the end of eight to sixteen hours of nursing intervention, the patient will be able to: 1. maintain a patent airway. 2. display reduction of congestion with breath INDEPENDENT: Monitor respiratory status including patterns, rate, depth, effort, and breath sounds.

Rationale

Evaluation SHORT TERM: Goals partially met. At the end of thirty minutes, patient needs assistance in expectorating but can breathe independently without the use of mechanical ventilation. LONG TERM: Goals partially met. After 8 hours, patient still has secretions but was managed properly, there were no episodes of respiratory distress, and adventitious breath sounds were diminished.

1.

1. Abnormal findings are indicative of respiratory distress and/or abnormal secretions. 2. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ ventilation to different lung segments 3. Hydration can help liquefy viscous secretions and improve secretion clearance. 4. To help in the mobilization of secretions.

2.

Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours)

3.

Facilitate increased fluid intake of at least 5 to 6 glasses per day as tolerated with aspiration precaution.

4.

Provide chest physiotherapy such as percussion and

 pale lips and nail beds

sound clear, noiseless respirations, improved oxygen exchange. 3. maintain O2 saturation at normal limits. 1.

vibration. Perform postural drainage, as necessary.

5.

Position head appropriately. COLLABORATIVE: 1. Administer oxygen at 1-2 LPM via nasal cannula as ordered.

5. To maintain proper airway.

1. To assist in the normal ventilation of the client. To ensure adequate oxygen administration. 2. To enhance lung expansion and treat underlying disease.

2. Administer medications as ordered: - bronchodilators: Salbutamol1 neb INH q6h; Duavent (ipatropium + albuterol) 1 neb INH q6h ; Dexamethasone2mg q6h IVTT; Epinephrine0.5cc + 1.5cc NSS INH q6h -antibioticsMeropenem (Meromax) 320 mg IV drip q8h;

Oxacillin sodium (Wydox) 400mg IV drip q6h; Clarithromycin(Klaricid) 125/5 mL 2.5 mL BID/NGT
2.

3. Monitor pulse oxygen saturation levels every four hours.

3. To ensure adequate oxygenation in the body. 4. To aid in the proper hydration

4. Continue intravenous line as ordered by physician.

CUES SUBJECTIVE: Naa pa man siya plema pero dili na kayo daghan as verbalized by mother OBJECTIVE:

NURSING DIAGNOSIS Impaired Gas Exchange related to ventilation perfusion imbalance

Nursing Care Plan 2 OBJECTIVES INTERVENTION SHORT TERM: Within 1 hour of providing nursing care and health teachings: a. the mother will be able to continue behaviors that alleviates respiratory distress of patient. b. the vital signs will be within normal limits. c. Demonstrate improved ventilation and adequate oxygenation as evidenced by oxygen saturation of 95-100%; INDEPENDENT: 1. Encourage and facilitate the mother to frequently change clients position.

RATIONALE

EVALUATION

- appears weak - Wheezing on both upper and lower lung fields noted upon auscultation -Sputum noted with copious, white in appearance - pale nail beds

SHORT TERM 1. Helps prevent GOALS ARE MET lung collapse and At the end of 1 mobilize secretions hour of providing nursing care and reinforcing the health teachings: 2. Elevate head of 2. Promotes the mother bed and position maximal lung was able to client appropriately inflation, and perform such as high back maintains airway techniques to rest especially patency. alleviate when client is in respiratory distress. distress (if anticipated) such as 3. Provide adequate 3. Reduces resting in high rest periods. oxygen back rest consumption and position, and demands. position changing at 4. Promote calm and 4. Helps limit frequent restful oxygen needs intervals; environment as Crackles and much as possible. wheezing are still present 5. Schedule nursing 5. The hypoxic upon care as much as client has limited auscultation; possible to provide reserves; however, patient rest and minimize inappropriate

d. will be free from signs and symptoms indicative of respiratory distress. LONG TERM: Within 16 hours of providing nursing care and health teachings, the patient will be able to: a. maintain improved ventilation and adequate oxygenation as evidenced by oxygen saturation of 95-100%;

fatigue.

activity can increase hypoxia 6. Reduces exposure to pathogens which could exacerbate the condition of the patient

remained free from respiratory distress. LONG TERM GOALS ARE MET At the end of 8 hours of nursing care, the patient: a. Demonstrat ed improved ventilation and adequate oxygenation as evidenced by oxygen saturation of 97% to 99%; b. remained free of signs of respiratory distress as evidenced by calmness of the patient and absence of nasal flaring.

6. Maintain environmental sanitation and personal hygiene.

DEPENDENT: 1. Administer medications, as ordered: 1. To treat/control infection and helps in improvings oxygenation and ventilation

>Meropenem (Meromax) 320 mg/q8h/IV drip >Oxacillin sodium (Wydox) 400mg/ IV drip/ q6h >Clarithromycin(Klaricid) 125/5 mL 2.5 mL BID/NGT >E-zinc 1ml/ OD/PO >Dexamethasone 2mg/IVTT/q6h >Salbutamol 1 b. Maintain clear lung fields neb/q6h/INH and remain free >Paracetamol 1 ml/q4h/PO/PRN for fever of signs of >Nalbuphine respiratory Hydrochloride (Nubain) distress such as nose flaring, 0.5mg/q8h/IVTT

retractions and restlessness

>Epinephrine 0.5cc + 1.5cc NSS/q6h/INH 2. Administration of Oxygen @ 1-2 LPM via nasal cannula as ordered (on standby). 2. To assist in the normal ventilation of the client. To ensure adequate oxygen administration.

COLLABORATIVE: 1. Refer to clinical instructor any other unusualities that will happen to the patient. 1. For prompt intervention and prevention of further complications