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explanation
April 26, 2010 Discharge outcome: independent: February 24, 2010
2:00PM inhales 12:00pm
Ineffective airway microorganism After 1 week of Monitor respiration To indicative of
Subjective: clearance related to nursing intervention and breath sound respiratory Discharge outcome:
retained mucus transmitted to alveoli the client will be able distress and/or
Stated: secretion as to: accumulation of Partially achieve
evidenced by Demonstrate secretion
“nahihirapan akong unproductive cough less behaviors to After 1 weeks of
huminga” as function(impaired improve or Encourage To loosen nursing intervention
verbalized by the gas exchange) maintain clear hydration at least secretion the client can be able
patient airway such as 8 glasses of to:
mucus production following water/day
(inflammatory pharmacologic Demonstrate
Objectives: reaction) regimen and Position head To open or behaviors to
doing pursed lip appropriate for maintain open improve or
Phagocyte produce technique condition such as airway in at rest or maintain clear
Inability to Demonstrate fowler’s position compromised airway such as
expectorate Accumulation of absence of individual following
phlegm exudates in alveoli mucus secretion pharmacologic
with breath Encourage To limit fatigue regimen and
Behavioral ⬆ mucus secretion sounds clear adequate rest doing pursed lip
changes: respiratory period technique
restlessness ineffective airway noiseless Collaborative
clearance
Short term out come: Assist with To maintain clear Short term outcome:
Adventitious procedure such as open airway
sound After 2 days of administering O2
Reference: medical nursing intervention Achieve
(crackles)
surgical nursing: 11th the client will be able Administer To promote
DOB edition volume 1 to: medication such pharmacologic After 2 days of
Brunner and Maintain airway as bronco dilators regimen nursing intervention
Suddarath clearance/patenc the client can be able
RR of 27 bpm y to:
Maintain proper Assist with A various
fluid volume monitor therapies may
Clear secretion hypothermia acquire/maintain Maintain airway
readily therapy use of adequate airways clearance/patency
respiratory device improve Maintain proper
and treatment respiratory fluid volume
function and gas Clear secretion
exchange readily