Assessment Subjective: Nahihirapan ako huminga as verbalized by the patient.

Objective: Dyspnea Productive Cough V/S taken as follows: T: P: R: Bp:

Diagnosis Ineffective airway clearance related to increased production of secretions.

Outcomes After 4 hrs. Of nursing interventions, the client will demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

Planning

Interventions

Rationale

Evaluation

Assist patient to assume position of comfort, e.g., elevate head of bed, encourage patient to lean on over bed table or sit on the edge of the bed. Keep environmental pollution to a minimum, e.g., dust, smoke and feather pillows, according to individual situation Assist with pursed lip breathing exercises.

Elevation of the head of the bed facilitates respiratory function by use of gravity.

Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode.

Provides patient with some means to cope or control dyspnea and reduce air trapping.

 Observe characteristics of cough like persistent or hacking or moist. Assist with measures to improve effectiveness of cough effort.

Coughing is most effective in an upright position or head down position after chest percussion.

Administer medication as prescribed by the physician.

A variety of medications may be used to decrease mucus and to improve respiration. Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles.

Provide supplemental humidification like nebulizer.

Assessment Subjective: Masakit ang dibdib ko as verbalized by patient. Objective: Use of accessory muscle. Dyspnea Fatigue. V/S taken as follows: T: P: R: Bp:

Diagnosis Acute pain related to localized inflammation and persistent cough

Outcomes After 4 hours of nursing interventions, the patient will display patent airway with breath sounds clearing and absence of dyspnea.

Planning

Interventions Independent: Elevate head of the bed, change position frequently.

Rationale Lowers diaphragm, promoting chest expansion and expectoration of secretions. Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Fluids especially warm liquids

Evaluation After 4 hours of nursing intervention s, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

Assist patient with deep breathing exercises.

Demonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position.

Force fluids to at least 3000 ml

per day and offer warm, rather than cold fluids.

aid in mobilization and expectoration of secretions.

Collaborative: Administer medications as prescribe: mucolytics or expectorants. Provide supplemental fluids. Aids in reduction of bronchospas m and mobilization of secretions. Fluids are required to replace losses and aid in mobilization of secretions.

Assessment

Diagnosis

Outcomes

Planning

Interventions

Rationale

Evaluation

Subjective: Hindi ako makatulog dahil sa ubo ko as verbalized by the patient. Objective: Fatigue. Dyspnea. V/S taken as follows: T: P: R: BP:

Actvity intolerance related to exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing and dyspnea.

After 4 hours of nursing interventions , the patient will demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive

Independent: Evaluate patients response to activity. Establishes patients capabilities or needs and facilitates choice of interventions Reduces stress and excess stimulation, promoting rest. These measures promotes maximal inspiration, enhance expectoratio n of secretions to improve ventilation. After 4 hours of nursing interventions , the patient was able to demonstrate a measurable increase in tolerance in activity with absence of dyspnea and excessive fatigue.

Provide a quiet environment and limit visitors during acute phase. Elevate head and encourage frequent position changes, deep breathing and effective coughing.

 Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake.
Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

Facilitates healing process and enhances natural resistance.

Fluids

especially warm liquids aid in mobilization and expectoration of secretions.

Collaborative:
Administer medications as prescribe: mucolytics or expectorants. Aids in reduction of bronchospas m and mobilization of secretions.