ASSESSMENT

NURSING DIAGNOSIS
Ineffective airway clearance related to bronchospasm and increase production of mucus secretions

PLANNING

NURSING INTERVENTION
y INDEPENDENT: 1. Auscultate breath sounds. Note adventitious breath sounds.

RATIONALE

EVALUATION

SUBJECTIVE: Medyo inuubo pa po ako as verbalized by the patient OBJECTIVE:

After nursing intervention, the patient will improve airway clearance and can demonstrate behaviors to improve her condition.

1. Some degree of bronchospasms present with obstructions in airway and may/may not be manifested in adventitious breath sounds. 2. To serve as s baseline data.

-wheezing upon expiration -V/S:

BP100/70mmHg T- 36 c PR- 71bpm RR- 18 bpm

2. Assess/Monitor respiratory rate. Note respiratory/expiratory ratio. 3. Advise high or semi fowlers position

After nursing intervention, the patient can improve airway clearance and can demonstrate coughing effectively and expectorating secretions.

3. Elevation of the head of the bed facilitates respiratory function by use of gravity and for optimum lung expansion. 4. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate onset of acute episodes. 5. Provide patient with some means

4. Keep environmental pollution to a minimum.

5. Encourage/assist with pursed-lip

breathing exercises.

to cope with control dyspnea and reduce airtrapping. 6. Cough can be persistent but ineffective. Especially if patient coughing is most effective in an upright or in a head-down position after chest percussion. 7. Hydration helps decrease the viscosity of secretions, facilitating expectorations. Using warm liquids may decrease bronchospasm. fluids during meals can increase gastric distention and pressure on the diaphragm.

6. Observe characteristics of cough. Assist with measures to improve effectiveness of cough effort.

7. Increase fluid intake within cardiac tolerance. Provide warm liquids. Recommend intake of fluids between, instead during, meals.

y DEPENDENT:

1. Administer medications as ordered by the doctor.

1. Antibiotics may be prescribed to treat the infection.

y COLLABORATIVE:

1. Assist in

administering nebulizer, as indicated.

1. This ensures adequate delivery of medications to the airways.

ASSESSMENT

NURSING DIAGNOSIS Ineffective breathing pattern related to constricted bronchial walls secondary to bronchospasm as evidenced by presence of mucus secretion

PLANNING

NURSING INTERVENTION
y INDEPENDENT: 1. Establish rapport.

RATIONALE

EVALUATION

OBJECTIVE: -wheezing upon expiration -fatigue -V/S:

BP100/70mmHg T- 36 c PR- 71bpm RR- 18 bpm

After nursing intervention, the patient will demonstrate breathing exercises.

1. To gain patient trust. 2. To obtain baseline Data 3. Serve to track important changes

2. Assess patients condition.

After nursing intervention, the patient can demonstrate breathing exercises.

3. Vital signs monitored and recorded.

4. Auscultate breath sounds and assess airway pattern

4. To check for the presence of adventitious breath sounds 5. To minimize difficulty in breathing

5. Elevate head of the bed and change the position of the pt. every 2 hours. 6. Encourage deep breathing and coughing exercises. 7. Demonstrate pursed-lip breathing.

6. To maximize effort for expectoration. 7. To decrease air

trapping and for efficient breathing. 8. Encourage increase in fluid intake 9. Encourage opportunities for rest and limit physical activities. 8. To prevent fatigue.

9. To prevent situations that will aggravate the condition

ASSESSMENT

NURSING DIAGNOSIS Infection related to inadequate primary defenses (stasis of secretions)

PLANNING

NURSING INTERVENTION
y INDEPENDENT: 1. Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.

RATIONALE

EVALUATION

OBJECTIVE: -with mucus secretion - Lab. Test: WBC13,800 (8,00010,000)

After nursing intervention, the patient will expectorate the sputum

1. These activities promote mobilization and expectoration of secretions to reduce risks of developing pulmonary infection. 2. Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection. 3. Prevents spread of fluid-borne pathogens.

After nursing intervention, the patient can expectorate the sputum

2. Observe color, character and odor of sputum.

3. Demonstrate and assist patient in disposal of tissues and sputums. Also proper handwashing and use gloves when handling/disposing of tissues, sputum containers. 4. Encourage balance between activity and rest.

4. Reduces oxygen consumption/demand imbalance, and improve patients resistance to infection, promoting healing. 5. Malnutrition can affect general wellbeing and lower-

5. Discuss need for adequate nutritional intake.

resistance to infection. 6. Recommend rinsing mouth with water and spitting, not swallowing. 6. Reduces localized immunosuppressive effect of drug and risk of oral candidiasis.

y DEPENDENT: 1. Administer antimicrobials as indicated.

1. May be given for specific organisms identified by culture sensitivity because of high risk.

ASSESSMENT

NURSING DIAGNOSIS Risk for imbalanced nutrition, less than body requirements related to decrease appetite due to present condition

PLANNING

NURSING INTERVENTION
y INDEPENDENT: 1. Assess dietary habits, recent food intake.

RATIONALE

EVALUATION

After nursing intervention, the patient will ingest daily nutritional requirements in accordance with her activity level and metabolic needs and will demonstrate behaviors changes to regain weight.

1. Patient in acute respiratory distress is often anorectic because of dyspnea, sputum production and medication. 2. To not aggravate the patients condition.

2. Instruct the diet indicated for her condition.

3. Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions. 4. Encourage a rest period of 1hr. before and after meals. Provide frequent small feedings. 5. Avoid gas-producing foods and carbonated beverages.

3. Noxious tastes, smells, and sights are prime deterrents to appetite and can produce N&V with increased respiratory difficulty. 4. Helps reduce fatigue during mealtime, and provide opportunity to increase total caloric intake. 5. Can produce abdominal distension, which hampers abdominal breathing and diaphragmatic

After nursing intervention, the patient can able to ingest her nutritional requirements in accordance with her activity level and metabolic needs and can demonstrate behaviors changes to regain weight

movement and can increase dyspnea. 6. Avoid very hot or very cold foods. 6. Extremes in temp. can precipitate/aggravate coughing spasms. 7. Useful in setting weight goal and evaluating adequacy of nutritional plan.

7. Weight as indicated.