Palomo, Axcel Dean G.

BSN 219 Cues Analysis Nursing Diagnosis Ineffective airway clearance related to retained secretions as manifested by productive cough and adventitious breath sounds Goals and Objectives Goal: After 8 hours of nursing intervention the client will have an effective airway Nursing Intervention Rationale Evaluation

S- the client s mother verbalized dumadalasnasiyanginuubo at sinisiponkasabayngpananakitngtiyanniya. O- the client has productive cough with yellow colored secretions The client has clear discharge on his nose. Presence of crackles on chest upon auscultation.

The respiratory system provides gas exchange by means of ventilation, oxygen transport and tissue perfusion; helps maintain acid-base balance and serve as an immune defense. A patient having ineffective airway clearance has an inability to clear secretions or

Objectives: After 5 minutes of discussing the importance of therapeutic management to the client s mother, the client s mother would be able to give 5

The nurse will discuss 5 out 5 importance of therapeutic management

Providing information on client promotes trust and cooperation of the patient to the nurse

Was the client be able to discuss 5 out 5 importance of therapeutic management? Yes: No: Why:

The nurse will encourage the

Deep breathing excersise and

Was the client

obstructions from the respiratory tract to maintain clear airway. If not treated, this might cause a serious respiratory problem. Nanda 11thed, p7781 Lippincott: MedicalSurgical Nursing.

out 5 importance of therapeutic management After 10 minutes of nursing intervention, the client would be able to expectorate secretions readily.

client to perform the deep breathing excersise and coughing exercise The nurse will be able to give expectorants and bronchodilators as ordered by the physician The nurse will encourage the client to increase fluid intake

coughing exercise be able to promote maximal expectorate mucous drainage secretions? Yes: No: Why: Expectorants assists in mucous expulsion and bronchodilators promotes easy respiration Hydration can help liquify viscous secretions and improve airway clearance Postural drainage and chest-physio therapy helps to remove mucous in the bronchioles

The nurse will perform and assist the client for postural drainage and chest-physio therapy The nurse will be able to assess and note client s

Noting clients response to treatment will help the nurse assess for progress

Was the client be able to demonstrate reduction of congestions with breath sounds clear

response to treatment After 30 minutes of nursing intervention, the client would be able to demonstrate reduction of congestions with breath sounds clear and respiration noiseless

The nurse will auscultate breath sounds and assess air movements

Auscultating and assessing air movement ascertain status and note progress. It is indicative of respiratory distress or accumulation of mucous secretion

and respiration noiseless? Yes: No: Why:

The nurse will monitor respiration and breath sounds noting rate and sounds The nurse will position head appropriate for age and condition

Positioning the head of the client appropriately maintain open airway in at rest or compromised individual Elevating the head of the bed or changing the position of the client take advantage of gravity decreasing pressure on the diaphgram and enhancing drainage of/ventilation of

Was the client be able to maintain patent airway? Yes: No: Why:

After 45 minutes of nursing intervention, the client will be able to maintain patent airway

The nurse will elevate head of bed or change client s position every 2 hours

as needed

different lung segments Keeping client s environment free from allergens will prevent the body s reaction/response from foreign substances which may contribute to the airway problem Nanda 11thed, p77-81

The nurse will keep client s environment free from allergens

Nelson G. Lacsamana Jr. BSN 211 Drug Classification Dosage and Preparation Indication Fever, headache, muscular aches and pain. Toothaches cold earache, fever due to tonsillectomy, inocculations and vaccinations. Promotes normal biochemical reactions. Strenghtens the immune system, supports normal growth and development. Helps prevent growth retardation in children and young adult. Contraindication Side-effects Nursing Responsibilities Check for physicians order. After administering, monitor vital signs q30. Specially temparature to note changes Check physicians order before administering the drug. Asses clients response to the drug. Administer proper dosage for the client.

Paracetamol (Tempra)

Analgesic; Anti-Pyretic

Tempra Syrup Childern 1-6 y/o: - 1 Teaspoon PRN; Q4

Renal or hepatic dse, cerebrovascular or hematologic disorders.

Skin rashes and other allergic reactions

Prozinc

Minerals

Young adult and Children: 2.5 5mL OD