Cues S: Medyo hirap syang huminga paminsanas verbalized by the relative of the client.

Nursing diagnosis

Planning Goal:

Nursing interventions 1. Monitor vital

Rationale

Evaluation

Ineffective Airway Clearance related to viscous mucus and retained secretions as manifested by difficulty of breathing After the nursing intervention the client will demonstrate a relief in breathing and maintain patent airway Objectives: a. Verbalize understan ding of cause and therapeuti c managem

1. This will help the health caregiver determine if there is alteration. 2. To determine if the amount of input and output intakes are adequate and provide guidelines for fluid replacement. 3. sound may reflect ateclactasis Rhonchi, wheezes indicate accumulation of secretion/ inability to clear airways that lead

After 8hrs of nursing intervention the client was able to show relief in breathing and maintaining patent airway a. the client was able to Verbalize understanding of cause and therapeutic management regimen. b. the client was able to state 3

signs 2. Monitor input and output intakes and correlates with weight changes. 3. Assess respiratory function, e.g., breath sounds, rate, rhythm and depth and use of accessory muscles diminishing 4. Assist the client to

O> The client showed mild difficulty of breathing during the interview. Facial Grimace Cough with occasional

phlegm Occasional mouth breather. Respiratory rate of 24.

ent regimen. b. State 3 out of 5 different ways on how to have a patent air maintenan ce c. Practice the instructed interventi on to on how to expectora te the mucous by the help of

position his head appropriately for age/ condition. . Assist patient with coughing and deep breathing exercise 5. Maintain fluid intake of at least 2500 ml/day unless contraindicate d 6. Clear secretions from mouth and trachea; suction as necessary. 7. Keep environment

to use of accessory muscles and increased work of cough 4. Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atclectatic areas and promote movement of secretion into larger airways for expectoration. Maximize effort. 5. High fluid intake helps thin secretion, making d. c.

out of 5 different ways on how to have a patent air maintenance

the client was able to practice the instructed intervention to on how to expectorate the mucos by the help of coughing exercise and maintaining patent airway

The client

coughing exercise and maintainin g patent airway

allergen free 8. Conduct health teaching to the client regarding cause(s) and therapeutic management regimen 9. Dependent: Administer bronchodilator s as physician required, and use of nebulization as necessary.

them easier to expectorate 6. Prevents obstruction/aspira tion. Suctioning may be necessary if the patient is unable to expectorate secretions 7. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. 8. Health teaching promotes wellness and awareness of the client. 9. To widened and relaxation of air f. e.

was able to show appreciation to the HCP. the client was able to follow continuity of care for the alteration. the client was able to show effortless breathing

passages. To reduce the viscosity of secretions.