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Nursing Diagnosis Patient Outcomes Nursing Interventions Rationale Evaluation

1. Introduce yourself to 1. This will help in the working relationship

Nursing the patient and folks at fostering trust.2. This will allow the proper
Diagnosis: Ineffective the first phase of care. alignment of the thorax thus opening the
Airway Clearance airway when at rest, especially when the
2. Place the patient in client is weak.
Related Factors: position wherein the
head is midline with 3. This will mechanically help the patient
1. Hyperplasia and flexion. breathe easier. Always observe sterile
hypertrophy of mucus- technique.
secreting glands  The patient will maintain 3. Suction nasal or oral
patency of airway. secretions as indicated. 4. Assessing the manner and pattern of
2.Increased mucus  The patient will effectively breathing may signal emotional or physical
production expectorate secretions. 4. Observe the patient stressors which may compromise normal
 The patient will be able to and its pattern of breathing.
3. Smoke inhalation manifest signs of good breathing.
oxygenation. 5. This will help mobilize the secretions *Refer to patient
4. Retained secretions  The patient will be 5. Teach the deep using the energy of the patient. In this way, outcomes tab
comfortable in terms of breathing and coughing the patient may know that he or she can help
5. Airway spasm ambulation and comply with exercises. himself or herself.
the health regimen.
Evidenced by: 6. Administer pain 6. Coughing can stimulate the pain receptors,
medications as ordered. it is better to provide analgesics before the
 Rales coughing exercise so that excretions of
 Persistent cough 7. Encourage increase mucus can be attained.
 Wheezing fluid intake as not
 Dyspnea contraindicated. 7. Hydration can also mobilize the secretions
 Restlessness clearing the upper airway as well as the
 Cyanosis 8. Splint the chest for lower airway.
8. Proper positioning can ease the patient
thus decreasing unnecessary effort.
9. Assist in mobilization
and provide proper
airway support.

10. Administer 9. Giving assistance may decrease the effort

mucolytic, in the side of the patient, while moving it is
bronchodilators as important to provide proper oxygenation in
ordered by the order to attain the desired move.

10. Collaboration with the physician in terms

of pharmacological intervention is also vital
in providing better outcomes.