Date and Time July 26, 2011 @ 7am

Cues Subjective:

Need Nursing Diagnosis Ineffective airway clearance related to thick tracheobronchial secretions secondary to Bilateral consolidative pneumonia Pneumonia is an inflammatory condition of the lungs especially the alveoli which can be associated with consolidation on a chest radiograph. Inflammation in the alveoli causes increase in mucous production from cellular debris and other substances. Thick secretions could impede the patients airway causing ineffective airway clearance. Smeltzer, S. Et.al. (2010).Brunner and Suddarths Textbook of medical Surgicial Nursing. Lippincott Williams and Wilkins. Philadelphia.

Objectives of Care Within 8 hours span of care, the patient will be able to maintain airway patency as evidenced by: a) loosening of secretions after nebulization; b) readily expectorating phlegm
c) eupnea- Maintain

Nursing Interventions
1. Assess

Evaluation July 26, 2011 @ 3pm Goal partially met At the end of 8hours span of care, the patient was able to maintain airway patency as evidenced by: a) loosening of secretions after nebulization b) readily expectorating phlegm c) Respiratory rate not within normal range: 28 cpm d) Presence of adventitious breath sounds e) Demonstrated effective coughing exercise to help maintain patency of airway

A C Dili magawas ang T I plema V I Objective: T Y Vital signs: E Temp-38.2 C X E Pulse-112bpm R cardiac-112 bpm C Respiration-40 cpm I S Blood Pressure- E 100/80mmHg P A T Fatigue T Craclkles heard E upon auscultation R N of both lung fields Body weakness Productive Cough Yellowish sputum Expels sputum minimal

2.

3.

normal RR d) Absence or Clearing of adventitious breath sounds

e) demonstrate 4.

behaviors to improve or maintain airway patency

5.

6.

Retractions of intercostals space

144 | P a g e

With nebulization of Salbutamol 1 neb q6

7.

airway patency Maintaining the patency is always the first priority. Assess respiration, note quality, rate, rhythm, depth, dyspnea Abnormality indicates respiratory compromise Assess level of consciousness and ability to protect own airway Information essential for identifying potential for airway problems, providing baseline level of care needed and influencing choice of intervention Evaluate respiratory depth Tachypnea is usually present in some degree and may be pronounced during respiratory stress Assess cough for effectiveness and productivity Consider possible causes ofor ineffective cough (respiratory muscle fatigue,severe bronchospasm; thick tenacious secretions) Note presence of sputum; assess quality, color, amount, odor and consistency Abnormalities may be a result of infection and other conditions. Elevate head of the bed/