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Ineffective Airway Clearance Related to Presence of Retained Secretions Secondary to PCAP

Date Cues Need Nursing Diagnosis Objective/Goal Nursing Interventions Evaluation

9/6/ Subjective: A Ineffective Airway After 3 hours span of 1. Monitor VS, especially Goal Met
10 “Lisod siya i- Clearance Related to effective nursing care, respiratory rate. @ 9:00pm
ginhawa. Naa C client will be able to: R: To evaluate degree of
6:00 Presence of Retained
man gud koy compromise and have At the end of 3
PM T Secretions Secondary
plema • Demonstrate baseline data hours span of
nakabara.” to PCAP nursing care the
I absence or
reduction of 2. Auscultate breath client:
R: The inflammation
Objective: V congestion with sounds, note areas of
and increased
• RR: 41cpm at secretions make it clearer breath decreased/adventitious • Showed signs
I breath sounds
rest difficult to maintain a sounds and in improvement
• Productive T improved oxygen R: To ascertain status and of breathing
patent airway which is
cough noted exchange note progress or and gas
caused by the
• Viscous Y complications. exchange as
decreased ability to
Yellowish expel the excessive • Demonstrate evidenced by a
E behaviors to 3. Elevate HOB, position on decrease in
sputum noted mucus produced
• Difficulty in improve or MHBR, and change position respiratory rate
X which leads to an
expectorating maintain clear every 2 hours as to 35cpm,
extensive obstruction
secretions E airway. necessary. though still
of the airway.
• Crackles R: To maximize respiratory above normal.
noted upon R Source: effort and mobilize
auscultation http://www.nurseslabs secretions. • Demonstrated
C
.com behaviors to
I 4. Keep environment improve or
allergen free. maintain clear
S R: To prevent allergic airway as
reactions. evidenced by
E positioning
5. Encourage client to herself on
P increase OFI to at least MHBR,
2000ml/day within level of increasing oral
A cardiac tolerance. fluid intake, and
R: To help liquefy maintaining
T secretions. bed rest.
T
6. Encourage adequate rest
E and limit activities within
client tolerance.
R R: To promote wellness.
N 7. Nebulize the patient as
indicated. Give
bronchodilators and other
respiratory agents ordered.
R: To promote liquefaction
of secretions as well as
prevention of
bronchospasms, thereby
aiding to loosen secretions.

8. Encourage adequate bed


rest.
R: To decrease oxygen
demands.

9. Provide information about


the necessity of raising and
expectorating secretions
versus swallowing them.
R: To report change in color
and amount in the event
that medical intervention
may be needed to
prevent/treat infection.
10. Render Health
teachings:
• Encourage breathing
exercises
• Encourage
compliance to
treatment regimen
• Instruct client to
increase OFI.