Ineffective Airway Clearance ASSESSMENT O: >wheezes/crackles upon auscultation on the BLF >with subcostal retraction >with nasal flaring

>presence of nonproductive cough >increase RR above normal range >restless DIAGNOSIS >Ineffective airway clearance related to retained and excessive secretions and ineffective coughing PLANNING > Short term:After 4-5 hours of nursing interventions the patient will demonstrate effective clearing of secretions Long term:After 2 days of nursing interventions, the patient will maintain effective airway clearance. NURSING INTERVENTIONS >>Establish rapport to the pt. and SO >Assess the patient condition >Monitor and record V/S >Position head midline with flexion on appropriate for age/condition >Elevate HOB >Observe S/Sx of infections >Auscultate breath sounds & assess air movt >Instruct the patient to increase fluid intake >Demonstrate effective coughing and deep-breathing techniques. >Keep back dry >Turn the patient q 2 hours >Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage. >Administer bronchodilators if prescribed. RATIONALE >>To gain trust and active participation >To know the condition of the pt >To have a baseline data. >To gain or maintain open airway >To decrease pressure on the diaphragm and enhancing drainage >To identify infectious process >To ascertain status & note progress >To help to liquefy secretions. >To maximize effort >To prevent further complications >To prevent possible aspirations >These techniques will prevent possible aspirations and prevent any untoward complications >More aggressive measures to maintain airway patency. EVALUATION >Short term: The patient shall have demonstrated effective clearing of secretions Long term:The patient shall have maintained effective airway clearance.

Ineffective Breathing Pattern ASSESSMENT S: Nahihirapan akong huming as verbalized by the pt. O: .:> with wheezes /crackles upon auscultation on BLF> increase RR above normal range >presence of productive cough >use of accessory muscle when breathing >presence of nasal flaring and retractions DIAGNOSIS PLANNING > Short term:After 4-5 hours of nursing interventions the patient will improve breathing pattern. Long term:After 2 days of nursing interventions the patient will maintain a respiratory rate within normal limits.>Establish rapport to the pt. and SO>Assess the patient condition>Monit or and record V/S especially RR>Provide rest periods NURSING INTERVENTIONS >Place pt in semifowlers position >Increase fluid intake >Keep patient back dry >Change position every 2 hours >Perform CPT >Place a pillow when the client is sleeping >Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate >Maintain a patent airway, suctioning of secretions may be done as ordered >Provide respiratory support. Oxygen inhalation is provided per doctors order >Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired. RATIONALE >>To gain trust and active participation> To know the condition of the pt >To have a baseline data. >To reduce fatigue and obtain rest >To have a maximum lung expansion >To liquefy secretions >To avoid stasis of secretions and avoid further complication >To facilitate secretion movt and drainage >To loosen secretion >To provide adequate lung expansion while sleeping. >To promote physiological ease of maximal inspiration >To remove EVALUATION > Short term:The patient shall have improved breathing pattern. Long term:The patient shall have maintained a respiratory rate within normal limits.

>Ineffective breathing pattern related to retained mucus secretions

secretions that obstructs the airway >To aid in relieving patient from dyspnea >To promote deeper respirations and cough

RISK FOR SPREAD OF INFECTION ASSESSMENT O: T-38.5C >dehydration >increase WBC count >presence of increase mucus production DIAGNOSIS >Risk for spread of infection related to stasis of secretions and decreased ciliary action. PLANNING > Short term:After 4-5 hours of nursing interventions the patient will identify interventions to prevent and/or reduce the risk of infection Long term:After 2 days of nursing interventions the patient will have minimize or totally be free from the risk of infection. NURSING INTERVENTIONS >>Establish rapport to the pt. and SO >Assess the patient condition >Monitor & record V/S >Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake >Turn the patient q 2 hours >Encourage increase fluid intake >Stress the importance of handwashing to SOs >Teach the SOs how to care for and clean respiratory equipment >Teach the SOs the manifestations of pulmonary infections (change in color of sputum, fever, chills) , selfcare and when to call the physician >Recommend rinsing mouth with water >Administer antimicrobial such as cefuroxime as indicated. RATIONALE >To gain trust and active participation >To know the condition of the pt >To have a baseline data and fever may be present because of infection and/or dehydration >These activities promote mobilization and expectoration of secretions to reduce the risk of developing pulmonary infection. >To facilitate secretion movt and drainage >To liquefy secretions >Handwashing is the primary defense against the spread of infection >Water in respiratory equipment is a common source of bacterial growth >Early recognition of manifestations can lead to a rapid diagnosis. EVALUATION > Short term:The shall have identified interventions to prevent and/or reduce the risk of infection Long term:The patient shall have minimized or totally be free from the risk of infection.

>To prevent risk of oral candidiasis. >Given prophylactically to reduce any possible complications