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ASSESSMENT and NURSING DIAGNOSIS S> Nahihirapan akong huminga O> calm and conversant; > skin is warm

to touch; > with dry mucous membrane; > with yellowish sclera, pale palpebral conjunctiva; > pale nail beds with capillary refill of 1-2 sec; > with dry lips; noted as a mouth breather; > Respiratory rate of 28cpm, regular, shallow, no nasal flaring and use of accessory muscle noted; > with spO2 of 92%; > with crackles heard over the lower lung lobes; > with coughing episodes; with productive cough, phlegm characterized as thick and whitish; >on O2 at 1-2 lpm via nasal cannula; > with v/s of BP: 160/90mmhg; PR: 80bpm; T: 36.7*C; > x-ray results revealed that the lungs are hypocierated

EXPLANATION OF THE PROBLEM Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough maybe ineffective in both normal and disease states secondary to factors such as respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions can overtax these mechanisms.

OBJECTIVES LTO - After 3 days/ 72 hours of nursing interventions the patient will maintain airway patency as manifested by independence from oxygen support and demonstrates reduction of congestions as manifested by clear breath sounds STO - After 8 hours of nursing interventions, the patient will be able to demonstrate behaviors to improve airway patency like coughing effectively and expectorating secretions and normal breathing pattern of 12-20cpm

NURSING INTERVENTIONS Assess changes in mental status

RATIONALE Increasing lethargy, confusion, restlessness, and/ or irritability can be early signs of cerebral hypoxia Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/ atelectasis Provides a basis for evaluating adequacy of ventilation

EVALUATION

Assess changes in vital signs

Monitor rate, rhythm, depth and effort of respirations Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostals muscle retractions Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds Monitor patients ability to cough effectively

Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation

As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds owing to fluid-filled air spaces and diminished lung volume Respiratory tract infections alter the amount and character of secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled.

Nursing Diagnosis: > Ineffective airway clearance related to

retained tracheobronchial tree secretions > Impaired gas exchange related to ventilation perfusion imbalance secondary to altered oxygen capacity of the blood > Ineffective breathing pattern related to body position

Assess the characteristics of the phlegm/ sputum

This may be a result of infection, bronchitis or other condition. Evaluate the status of oxygenation/ ventilation Lying flat causes the abdominal organs to shift toward the chest, crowding the lungs and making it more difficult to breath A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions Deep breathing promotes oxygenation before controlled coughing Controlled coughing is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of abdominal and chest muscles

Note changes in SpO2 Assist in a semi-fowlers position

Institute respiratory therapy treatments as ordered (eg. Nebulization) Encourage to take several deep breaths

Encourage to take deep a deep breath, hold for 2 seconds, and cough two or three times in succession

REFERENCES: Doenges, M.E., et. al, Nurses Pocket Guide, 12th Edition Kozier & Erbs Fundamental of Nursing, 8th Edition Brunner & Suddarths Medical- Surgical Nursing, 12th Edition Emedicine.medscape.com/ Nursingscrib.com/Scribd.com

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