Problem Identification Significant Cues Nursing Diagnosis

Subjective: His grandmother said that Client C has cough and colds for almost 2 weeks and Ineffective Airway Clearance related to bronchospasm possibly evidenced by cough she recognized that her grandson has irregular breathing pattern or has with sputum production difficulty of breathing. His grandmother said that their place has no enough ventilation and light because she said that kailangan pang lumabas ng bahay o kaya buksan ang pintuan at mga bintana para mapasukan ng hangin ang loob ng bahay. She also added that kung lalabas ka nga ng bahay para lumanghap ng hangin, pollution naman ang masisinghot mo dahil sa mga usok ng tricycle at mga sasakyan.

Objective: Coughing with sputum production Use of accessory muscle Measurements: RR: 79 cpm PR: 170 bpm

Subjective: His grandmother said that Client C has cough and colds for almost 2 weeks and she recognized that her grandson has irregular breathing pattern or has difficulty of breathing. Objective: Tachypnea The client shows irritability and body weakness restlessness

Ineffective breathing pattern related to musculoskeletal impairment (weakness of the muscles of the throat) possibly evidenced by tachypnea

Measurements: RR: 79 cpm PR: 170 bpm

Objective: Restlessness Inability to move secretions Measurements: Pulse Rate:170 bpm Respiratory Rate:79 cpm Oxygen Saturation: 90

Impaired gas exchange related to altered oxygen supply (obstruction of airway by air trapping) possibly evidenced by restlessness.

IX. Problem Prioritization Rank Nursing Diagnosis Ineffective Airway Clearance related to bronchospasm possibly evidenced by cough with sputum production Justification Nature of the problem High priority due to inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Maslows hierarchy of needs High priority because it affects the clients physiologic needs. According to Maslows Hierarchy of Needs, breathing and good body circulation must be met by the client. Clients priorities, values and beliefs If the cough and sputum production become more severe, it can be life threatening. Resources obtainable to the nurse and client materials, money, man power, time

knowledge and skills are capable to the nurse Ineffective breathing pattern related to musculoskeletal impairment (weakness of the muscles of the throat) possibly evidenced by tachypnea Nature of the problem Medium priority because inspiration and/or expiration that does not provide adequate ventilation. Maslows hierarchy of needs According to Maslows Hierarchy of Needs, Air as one of the physiologic needs must be met by the client. Clients priorities, values and beliefs If the tachypnea becomes more severe, it can be health threatening. Resources: obtainable to the nurse and client materials, money, man power, time knowledge and skills are capable to the nurse Impaired gas exchange related to altered oxygen supply (obstruction of airway by air trapping) possibly evidenced by restlessness. Nature of the problem Medium priority due to deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capiliary member. [this maybe an entity of its own, but also maybe an end result of other pathology with an interrelatedness between airway clearance and/or breathing pattern problems] Maslows hierarchy of needs According to Maslows Hierarchy of Needs, oxygen as one of the physiologic needs must be met by the patient. Clients prioritization, values and beliefs If the inability to move

secretions becomes more severe, it can be health threatening Resources: obtainable to the nurse and client materials, money, man power, time knowledge and skills are capable to the nurse