The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.
The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.
The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.
The document contains an assessment, diagnosis, plan, rationale, and evaluation for a patient with ineffective airway clearance. The plan involves 1) educating the patient on breathing exercises and hydration, 2) assessing breath sounds, and 3) suctioning or administering medications as needed. The goals are to clear the airways after 1 day and identify factors inhibiting clearance after 2 weeks. After intervention, the patient's airways remained clear and goals were met.
Subjective Data: Ineffective Short term: Independent: Independent: Short term:
“Inuubo siya airway After 1 day of Educate the patient to To improve lung function After 1 day of tuwing gabi dahil clearance nursing intervention the practice deep breathing and help with mucus nursing intervention the sa lamig” as related to patient will be able to exercise. clearance. patient was able to verbalized by the cough as maintain clear, open maintain clear, open SO of patient evidenced by airways as evidenced by Auscultate breath sounds To ascertain current status airways as evidenced by dyspnea the absence of abnormal and assess air movement. and note effects of treatment the absence of abnormal Objective Data: breath sounds. in clearing airways. breath sounds. (+) presence of dyspnea Long term: Encourage the patient to Maintaining adequate “GOAL MET” (+) ineffective After 2 weeks of maintain adequate hydration helps in thinning cough nursing intervention the hydration. respiratory secretions, Long term Goal patient will be able to making them easier to After 2 weeks of Vital Signs: identify and avoid mobilize and clear from the nursing intervention the T: 36.5 ̊C specific factors that airways. patient was able to HR: 76 bpm inhibit effective airway identify and avoid RR: 24 bpm clearance. Dependent: specific factors that BP: 90/60 mmHg Dependent: Suctioning is needed when inhibit effective airway Perform nasotracheal clients are unable to cough clearance. suctioning as necessary, out secretions properly due especially if the cough is to weakness, thick mucus ineffective. plugs, or excessive or “GOAL MET” tenacious mucus production.
To help the patient improve
Administer medications as airway patency and promote prescribed by the physician. effective secretion clearance.
Collaborative: Collaborative: Collaborate with To allow a pulmonologists. comprehensive assessment of the patient’s respiratory status.
