Date 08-3011

Cues Subjective:

Nursing Diagnosis Ineffective airway clearance related to infection

Knowledge Back ground Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway (NURSES POCKET GUIDE, by Doenges ,Marilyn E. pg. 80)

Objective

Nursing Intervention Monitor respirations sand breath sounds, noting rate and sounds (ex. Wheezes, crackles, tachypnea) Position head appropriate for age and condition

Rationale

Evaluation

Signature

Objective: Productive cough Changes in respiratory rate/rhythm Diminished breath sounds (Crackles, Wheezes)

After nursing 8 hours intervention s the client will maintain airway patency

Indicative of respiratory distress and accumulation of secretions

To open or monitor open airway in at rest or comprised individual To ascertain status and note progress

Auscultate breath sounds and assess air movement

Monitor VS, noting changes in BP and HR

To gather baseline data

 Observes sign and symptoms of infection

To identify infectious process and promote timely intervention

Encourage/ provide for rest; Limit activities to level of respiratory tolerance

To prevent or reduces fatigue

Date 08-3011

Cues Subjective:

Nursing Diagnosis Ineffective breathing pattern related to cognitive impairement

Knowledge Back ground Inspiration and or expiration that does not provide adequate pattern (NURSES POCKET GUIDE, by Doenges ,Marilyn E. pg. 151)

Objective

Nursing Intervention Determine presence factors/ physical conditions as noted in related factors Auscultate chest

Rationale

Evaluation

Signature

Objective: Nasal Flaring Dyspnea

After nursing 8 hours interventions the client demonstrate appropriate coping patterns

That would case breathing impairement

To evaluate present character of breath sounds and secretions Anxiety maybe causing or exacerbating acute or chronic hyperventilat ion To assist client in taking control of the situation

Note emotional responses

Encourage slower deeper respirations, use of pursed-lip technique