Subjective: Ineffective Ariway Bacterial/ Viral Short term goal: Independent:
Nahihirapan akong Clearance related to Invasion Deep breathing After 8 hours of humingi (Its difficult the increased After 8 hours of Encourage deep promotes nursing to breathe) as production of nursing breathing oxygenation intervention, goal verbalized by the respiratory secretions intervention, exercises before controlled partially met. patient. secretions will be Assist patient in coughing The patient was Multiplication of mobilized, airway coughing To improve able to > Objective: bacteria /virus; patency will be exercises productivity of demonstrate Rapid breathing/ enters the luns maintained free of Increase fluid the cough. coughing and tachypnea secretions, as intake, as Adequate fluid deep breathing Cough with yellow evidenced patients appropriate intake enhances exercise every 1-2 sputum production ability to effectively Monitor rate, liquefaction of hours during the Diminished and Cells of the immune cough out rhythm, depth, pulmonary day adventitious breath system gathers in secretions, clear and effort of secretions and sounds (crackles) lungs to stop lung sounds, and respirations. facilitates > Clients Dyspnea infection uncompromised Assist patient expectoration of respiratory rate is VS taken as respiratory rate. into moderate mucus. within normal follows: high back rest Provides a basis range (RR 19) position for evaluating T 36.9 C Auscultate lung adequacy of > Inspiratory P 89 bpm fields, noting ventilation crackles can still RR 36 br/min Inflammation & areas of To promote be heard at the BP 130/80 mmHg production of decreased of drainage of right lower lobe secretions increase absent airflow secretions and and adventitious better lung > cough breath sounds expansion continues to be Student Nurses Community Decreased airflow productive. Pulmonary infection occurs in areas Dependent: consolidated with Administer fluid. Bronchial sputum production; ordered breath sounds excess, medications (normal over accumulated such as bronchus) can secretion in the mucolytic also occur in airways agents, consolidated bronchodilators, areas. Crackles, expectorants rhonchi, and Administer wheezes are airway blockage nebulizations as heard on needed inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstructio n. To help loosen and clear the mucus from the airways (mucolytics); decrease resistance in the respiratory airway and increase airflow to the Student Nurses Community lungs (bronchodilators) and to loosen and clear mucus and phlegm from the respiratory tract (expectorants) A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions.