Nursing Diagnosis: Ineffective airway clearance related to retained bronchial secretions secondary to chronic maxillary sinusitis, as manifested by respiratory
rate of 30breathsƒminute,
productive cough with whitish phlegm, clear nasal discharge, and feeling of anterior chest heaviness.
Cues Goals of care
Within 8 hours of clinical
Objective: duty, patient will be able to:
• Respiratory rate
30breathsƒminute • Maintain patent
• Whitish phlegm airway.
approximately 10cc • Verbalize causative
per expectoration factors that lead to
• Clear nasal discharge chronic maxillary
• Anterior chest sinusitis
heaviness rated as • Appropriately cough
4ƒ10. out secretions using
coughing exercises
Subjective: • Lessened bronchial
• “ a ubo−ubo ako and nasal discharges
gamay kag daw okay • Able to practice
naman akon appropriate deep
sip−on…. Ang dughan breathing exercises
ko daw bug−at lang • Decreased feeling of
akon pamatyagan”. anterior chest
heaviness
Nursing Interventions
Independent:
• Establish baseline vital signs,
specifically respiratory rate
• Auscultate lung sounds on
anterior and posterior
thorax
• Elevate client’s head;
semi− fowler’s position
• ive chest physiotherapy
Health teachings:
• Health teachings about
environmental factors such
as allergens that could
contribute to sinusitis
• Teach patient to perform
proper coughing techniques
• Teach how to do
appropriate deep breathing
exercises
Therapeutic
• Encourage adequate rest
• Provide a clean and allergen
free environment
• Increase fluid intake
Collaborative
• Administer medications as
prescribed; expectorants,
bronchodilators.
Rationale
• To identify alterations in
respiratory status
• To assess area of
consolidation
• To facilitate breathing
• To mobilize secretions
• To prevent
reoccurrence of
infections
• To appropriately
cough out secretions
• To encourage lung
expansion
• To promote wellness
• Avoid allergic reactions
• Help loosens phlegm,
prevent dehydration
• Aids in preventing
bronchospasm and
liquefy secretions
Evaluation Patient’s response
DONE • Baseline vital signs: T− 36.8; RR−
25breathsƒmin; CR−
76beatsƒminute;CR−76beatsƒminute;
BP − 100ƒ70mmHg.
DONE • No adventitious sounds noted on
anterior and posterior thorax
DONE • Able to tolerate 45o position
DONE • Able to cough out secretions
DONE • Able to enumerate environmental
factors that could contribute to
chronic maxillary sinusitis such as
dusts, pollens,bacteria, strong odors.
DONE • Able to perform half cough
DONE • Able to do deep breathing exercises
DONE • Verbalized to have adequate rest
DONE
• Does not manifest signs and
symptoms of allergic reactions
DONE
• Verbalized to regularly drink
8−10 glasses of water a day
• Does not manifest signs and
DONE
symptoms of bronchial spasm.
• Expectorate to clear whitish sputum
 approximately 5cc. (better prior to
admission)
• Patent bilateral nares, verbalized to
have lessened nasal discharge
• Respiratory rate of 24 breaths per
minute, unlabored.
• Verbalized decreased feeling of
anterior chest heaviness rated as
3ƒ10

• Provide recommended • To supply oxygen DONE • No sign of oxygen deprivation.

treatments: oxygen demand, and to maintain Maintains patent nares and good
support, nasal sprays. good nasal hygiene. nasal hygiene.

General Evaluation:
After giving nursing interventions, goals were met. Client does not manifest any sign of pulmonary distress, has patent bilateral nares, able to perform deep breathing
exercises, cough out decreased bronchial secretions appropriately using half cough, verbalized lessened nasal discharge and feeling of anterior chest heaviness rated as 3ƒ10.