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1. The patient was experiencing difficulty breathing due to a cold and cough, with excessive secretions in the lungs secondary to pneumonia.
2. The nursing care plan's short term goal was to mobilize secretions and maintain an open airway within 8 hours of intervention.
3. After 8 hours of monitoring breathing patterns, assisting with secretion removal, and postural drainage, the patient no longer had adventitious lung sounds and was able to cough and breathe deeply every 1-2 hours.
1. The patient was experiencing difficulty breathing due to a cold and cough, with excessive secretions in the lungs secondary to pneumonia.
2. The nursing care plan's short term goal was to mobilize secretions and maintain an open airway within 8 hours of intervention.
3. After 8 hours of monitoring breathing patterns, assisting with secretion removal, and postural drainage, the patient no longer had adventitious lung sounds and was able to cough and breathe deeply every 1-2 hours.
1. The patient was experiencing difficulty breathing due to a cold and cough, with excessive secretions in the lungs secondary to pneumonia.
2. The nursing care plan's short term goal was to mobilize secretions and maintain an open airway within 8 hours of intervention.
3. After 8 hours of monitoring breathing patterns, assisting with secretion removal, and postural drainage, the patient no longer had adventitious lung sounds and was able to cough and breathe deeply every 1-2 hours.
Subjective: Ineffective Airway Short term goal: > Monitor -> With secretions After 8 hours of Clearance related respiratory in the airway, the Nursing Intervention, “nahihirapan po to excessive After 8 hours of patterns, including respiratory rate will the Pt’s breathing akong huminga accumulation of nursing rate, depth, and increase had no more dahil sa sipon at secretions intervention, effort. adventitious sounds ubo ko” as secondary to secretions will be (crackles/gargles) verbalized by the pneumonia. mobilized , airway > Assist with > It is preferable for present when patient. patency will be clearing the client to cough auscultated . maintain free of secretions from up secretions. Objective: secretions, as pharynx by Gentle suctioning The patient was able -Rapid breathing evidenced offering tissues of the posterior to demonstrate patient’s ability to and gentle suction pharynx may coughing and deep -Cough with effectively cough of the oral stimulate coughing breathing exercise yellow sputum out secretions, pharynx if and help remove every 1-2 hours production Pt’s breathing will necessary secretions during the day. have no more -Diminished and adventitious adventitious sounds present breath sounds (crackles/gargles) > Provide postural > Chest physical (crackles) when auscultated drainage, therapy helps and percussion, and mobilize bronchial -Dyspnea uncompromised vibration as secretions respiratory rate. ordered -VS taken as follows: > Administer > Bronchodilators medications such decrease airway T- 36.7 as bronchodilators resistance P- 89 bpm or inhaled steroids secondary to RR- 14 cpm as ordered. bronchoconstriction BP- 100/70mmHg NURSING CARE PLAN