NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) S: None NURSING DIAGNOSIS (Problem and Etiology)

Ineffective airway clearance related to presence of mucous secretions. GOALS AND OBJECTIVES NURSING INTERVENTIONS AND RATIONALE EVALUATION At the end of 5-15 mins. of nursing interventions the patient was able to secrete mucous secretions and airway was patent.

O: (+) Mucous secretions @ both lungs noted (+) Crackles noted Difficulty in breathing noted Ineffectective coughing noted

At the end of 5-15 mins. Dependent: of nursing interventions Instructed to increase fluid the patient will be able to intake. secrete mucous R: To liquefies the mucous and will secretions and will have be easy to expectorate. a patent airway. Proper coughing exercise was demonstrated. R: In order for the patient to have proper coughing and will expectorate mucous easily. Encouraged to do deep breathing exercises. R: To promote Lung expansion. Proper postural drainage was taught. R: For the easy expectoration of the mucous through the gravity. Chest tapping done prior to nebulization. R: For the mucous will be soften and now be ready to expectorate. Kept back dry and clean. R: To prevent bed sores and to avoid more complications in respi. Positioned head of the bed 450 R: Promotes more lung expansion and gas exchange. Independent: Administer drugs as prescribed by the physician.

NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective Cues) S: None NURSING DIAGNOSIS (Problem and Etiology) Impaired gas exchange related to accumulation of too much mucous secretions in the alveoli secondary to CAP GOALS AND OBJECTIVES At the end of 8 hours of nursing interventions the patient will demonstrate improved ventilation. NURSING INTERVENTIONS AND RATIONALE Dependent: RR, use accessory muscles & pursed lip breathing was noted R: To evaluate degree of compromise. Pulse oximetry to determine oxygenation was evaluated R: To assess for respiratory insufficiency. Elevate head of the bed. R: To maintain patent airway Instructed to do deep breathing exercises and coughing exercises. R: To expectorate mucous. Encouraged to Increase fluid intake. R: To liquefy secretions Encouraged Bed rest R: To reduce oxygen need and consumption. Repositioned the client. R: For optimal lung expansion Independent: Administer drugs as prescribed by the physician. EVALUATION At the end of 8 hours of nursing interventions the patient was able to demonstrate slight improvement in ventilation.

O: Restlessness noted Productive cough noted Adventitious breath sounds With O2 administration noted O2 sat = 93%

NURSING CARE PLAN

ASSESSMENT DATA (Subjective & Objective Cues) S: None

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION At the end of 5-15 mins. of nursing interventions the patient was to secrete mucous secretions and airway was patent.

O:

At the end of 5-15 mins. Dependent: of nursing interventions Instructed to increase fluid the patient will be able to intake. secrete mucous R: To liquefies the mucous and will secretions and will have be easy to expectorate. a patent airway. Proper coughing exercise was demonstrated. R: In order for the patient to have proper coughing and will expectorate mucous easily. Encouraged to do deep breathing exercises. R: To promote Lung expansion. Proper postural drainage was taught. R: For the easy expectoration of the mucous through the gravity. Chest tapping done prior to nebulization. R: For the mucous will be soften and now be ready to expectorate. Kept back dry and clean. R: To prevent bed sores and to avoid more complications in respi. Positioned head of the bed 450 R: Promotes more lung expansion and gas exchange. Independent: Administer drugs as prescribed by the physician.