ASSESMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
Subjective: Ineffective Maintaining a Within the 8˚ - establish rapport - to facilitate Goal partially
“inuubo p rin sya” airway clearance patent airway is shift, the client cooperation as well met. After the
as verbalized by r/t retained vital to life. will be able to as to gain pt’s trust shift, the client
the grandmother. bronchial Coughing is the demonstrate - position the patient - to promote was able to
secretions main mechanism behaviors to comfortably comfort demonstrate
Objective: for clearing the improve clear - monitor vital signs - to note any behaviors to
- received awake airway. However, airway by significant changes improve clear
lying on bed ĉ the cough may be expectoration of that can affect the airway but
ongoing IVF of #6 ineffective in both retained pt’s condition wasn’t able to
D5IMB iL @ 950cc normal and secretions. - elevate head of - These promote expectorate
remaining level to disease states bed better lung retained
run for 12o, secondary to expansion and secretions.
infusing well @ left factors such as improved air
hand pain from surgical exchange
- conscious and incisions/ trauma, - Auscultate lungs for - These may
coherent respiratory presence of normal indicate presence
- ĉ productive muscle fatigue, or or adventitious of mucus plug or
cough neuromuscular breath sounds other major airway
- ĉ good skin weakness. Other obstruction
turgor mechanisms that - Assess - Abnormality
-ĉ good capillary exist in the lower respirations; note indicates
refill in 2-3 secs bronchioles and quality, rate, pattern, respiratory
- s respiratory alveoli to maintain depth, flaring of compromise
distress (RR: 26 the airway include nostrils, dyspnea on
CPM) the mucociliary exertion, and position
- on HAD system, for breathing
- ĉ good appetite, macrophages, - Assess cough for - Consider possible
consumed all of and the effectiveness and causes for
the food served lymphatic. productivity ineffective cough
- ambulatory Factors such as (e.g., respiratory
- afebrile (36.7 oC) anesthesia and muscle fatigue,
dehydration can severe
affect function of bronchospasm, or
the mucociliary thick tenacious
system. Likewise, secretions).
conditions that - Assist patient in - These improve
cause increased performing coughing productivity of the
production of and breathing cough
secretions (e.g., maneuvers
pneumonia, - encourage increase - Increased fluid
bronchitis, and oral fluid intake intake reduces the
chemical irritants) viscosity of mucus
 DRUG STUDY

BRAND GENERIC DOSAGE ACTION INDICATION CONTRAINDICATION NURSING

NAME NAME CONSIDERATIONS
Ventolin Salbutamol 5 ml, TID Stimulates beta-2 Relief of Hypersensitivity to  Assess cardio-
Expectorant receptors of bronchioles bronchospasm in salbutamol, also to respiratory function;
by increasing levels of bronchial asthma, atropine and its BP, heart rate and
cAMP which relaxes chronic bronchitis, derivatives. Threatened rhythm, and breath
smooth muscles to emphysema and other abortion during the first sounds.
produce reversible, obstructive or second trimester.  Determine history
bronchodilatation. Also pulmonary diseases. Cardiac arrhythmias of previous
causes CNS stimulation, Also useful for treating associated with medication
cardiac stimulation, bronchospasm in tachycardia caused by (theophylline), and
increased diuresis, patients with co- digitalis intoxication. ability to self
skeletal muscle tremors, existing heart disease Hypertrophic medicate to prevent
and increased gastric of hypertension. obstructive additive.
acid secretion. Longer cardiomyopathy or  Monitor for
acting than isoproterenol. tachyarrhythmia. evidence of allergic
Thyrotoxicosis. reactions and
Prevention of paradoxical
premature labor bronchospasm.
associated with
toxemia of pregnancy
or antepartum
hemorrhage. Lactation.
Use of non-selective
beta-blockers.
BRAND GENERIC DOSAGE ACTION INDICATION CONTRAINDICATION NURSING
NAME NAME CONSIDERATIONS
Tergicef Cefixime 5 ml, TID Inhibits bacterial cell wall Bronchitis, Hypersensitivity.  Assess patient’s
synthesis, rendering cell bronchiectasis with History of shock due to previous reaction to
wall osmotically unstable, infection, secondary any ingredient of this penicillin or other
leading to cell death. infections of chronic product. cephalosporins.
respiratory tract Cross-sensitivity
diseases, pneumonia, between penicillin
otitis media, sinusitis. and cephalosporins
Pyelonephritis, cystitis, is common.
gonococcal urethritis,  Assess patient for
cholecystitis. Scarlet signs and symptoms
fever. of infection before
and during
treatment; fever,
earache,
characteristics of
wounds, sputum,
urine, stool, and
WBC >10,000/mm3
 Obtain C&S
before beginning
drug therapy to
identify if correct
treatment has been
initiated.
 Assess for allergic
reactions.
 Assess renal
function before and
during therapy; urine
output. BUN and
creatinine.