NURSING CARE PLAN Cues Nahihirapan akong humingi at sumasakit din minsan ang dibdib ko .

parang naghahabol ako ng hininga,, the client verbalized. y Respiratory rate: 27 bpm y dyspnea y chest pain y thick secretion y forceful cough Nursing diagnosis Ineffective airway clearance due to retained secretions, weakness, bad cough efforts Goal and objectives After 1 week of nursing intervention, the client will have an effective airway clearance. Objectives: - to expectorate secretions effectively - to maintain airway patency - to decrease bronchoconstriction -advise the client to increase fluid intake to atleast 2000 ml/ day within cardiac tolerance. -position appropriately (head of the bed elevated, side lying, semi fowlers/ fowlers) - encourage bed rest. -assist client with postural drainage and percussion as indicated. Intervention Independent: -encourage deep breathing exercise and coughing exercise Rationale Evaluation Does the client have an effective airway clearance after 1 week of nursing intervention? __yes __no Why?

- This technique can help increase sputum clearance and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective -hydration can help liquefy viscous secretions and improve secretion clearance. - to facilitate breathing and assist secretion clearance.

- to decrease fatigue. - helps to facilitate airway clearance/ remove secretions.

Dependent: - give analgesics as prescribed by the attending physician. - give expectorants or bronchodilators as prescribed by the attending physician. - to improve cough when pain is inhibiting effort. - helps to easily removing of secretions by dilating the bronchus.