Subjective: Ineffective airway Within 1 hour of 1. Maintain adequate 1. To prevent further aggravation / After an hour of clearance r/t airway nursing patent airway complication. nursing intervention, “Nahihirapan akong spasm and allergic intervention, • Keep client in a wide • Improve air ventilation, reduce the client was able to huminga” as airways the patient will space, allergen-free anxiety and prevent further demonstrate improved be able to environment aggravation. air exchange as verbalized by maintain airway depending on the • Semifowler position helps evidenced by: patient. OR patency individual situation. RR=12-20 breaths per maximize lung expansion and demonstrating Open the doors and ventilation. This position uses gravity minute Impaired gas exchange absence or windows or keep to pull the diaphragm downward PR=60-100 bpm Objective: r/t decreased airway reduction of bystanders away. BP=120/80 diameter breathing. • Assist client in a • Orthopneic position is helpful Normal breathing / distant adventitious for clients who have problems semi-fowler or lung sound. sounds heard by orthopneic position. exhaling. This position allows Client was also able INFERENCE maximum lung expansion and then to expectorate phlegm auscultation, Triggering factors of allows the client to press his/ her and verbalized wheezing, coughing, asthma causes 2. Mobilize secretions lower part of the chest against the “Nakakahinga na ako inflammation of the head of the overbed upon exhaling. ng maluwag” use of accessory airways which leads to • Encourage and instruct the client to 2. Deep breathing exercises and coughing muscle while contraction of the helps remove secretion from airways. bronchial smooth muscle. perform breathing and coughing • (To follow: Drug study) This is breathing, difficulty This will reduce the exercise. a dependent nursing action vocalizing, presence airway diameter and • Nebulizers or steam delivers a excessive mucus • Give medicines as prescribed by doctor fine spray of medication or moisture of sputum production. to client. It dilates the airways and RR=40 breaths per • Provide loosens mucous secretions Inability to clear humidification, minute secretions and obstruction nebulizer/ steam PR=110 bpm from the respiratory tract inhalation with saline will lead to difficulty of solution BP=130/100 breathing, decreased oxygenation, air hunger, etc.
Reference: NANDA, Brunners and Suddarth, Kozier, Pearson’s Pathophysiology
Martin Zenker-Noonan Syndrome and Related Disorders - A Matter of Deregulated Ras Signaling (Monographs in Human Genetics Vol 17) - S. Karger AG (Switzerland) (2009)