ASSESSMEN

T
Objective:
Presence of
Rhonchi
productive
Cough with
whitish
sputum
V/S:
T: 38.4 C
P: 92bpm
R: 20bpm
BP: 110/80

NURSING
DIAGNOSI
S
ineffective
airway
clearance
related to
excessive,
thickened
mucous
secretions

NURSING
OBJECTIVE

NURSING
INTERVENTI
ON

short term:
After 30 mins.
of
nursing
interventions
the patient
will:

Demonstrate
improved
ventilation
and
adequate
oxygen.
Arterial
blood
gases (ABGs)
within normal
range.
No signs of
respiratory
distress.

1. Assess
respiratory.ra
te, depth.
Note use
of accessory
muscles,
pursed lip
breathing,
Inability to
speak.
2. Elevate
head of the
bed, assist
patient
assume
position to
ease work of
breathing.
Encourage
deep slow or
pursed
lip breathing
as
individually
tolerated
or indicated.

RATIONALE

EVALUATIO
N

Patient
1.Useful in
display
evaluating
improved
the degree or ventilation
respiratory
and
distress
free
and
from
chronicity of
symptoms
the
of respiratory
disease
distress.
process.
2.Oxygen
delivery
may be
improved by
upright
position and
breathing
exercises
to decrease
airway
collapse,
dyspnea
and work of
breathing.

3. Routinely
monitor skin
and mucous
membrane
color.

4. Encourage
expectoratio
n of
sputum;
suction when
indicated
.

3.Cyanosis
may be
peripheral in
nail
beds or
central in
lips or
earlobes.
Duskiness
and
central
cyanosis
indicate
advanced
hypoxemia.
4.Thick,
tenacious,
copious
secretions
are major
source if
ineffective
airways.

ASSEMENT

Objective:
-Body temperature
above normal
range (38.4 c)
-Increase WBC
count
-Presence of

NURSING
DIAGNOSIS

OBJECTIVE

-Risk for Spread

-After 30
mins of
nursing
intervention
the pt. will:

of Infection RT
Stasis
of Secretions &
Decreased Ciliary
Action

-Normalize
body temp.
from 38.437.3C

increase mucus
production

-Patient will
identify
intervention

NURSING
INTERVENTION
-Monitor vital signs.
-Review importance
of breathing
exercises, effective
cough, frequent
position changes,
and adequate fluid
intake

reduce the
risk of
infection

EVALUATION

-For baseline
data

-After 30 mins
of nursing
intervention
the pt. had:

-Stress the
importance of
handwashing

- These
activities
promote
mobilization
and
expectoration
of secretions
to reduce the
risk of
developing
pulmonary
infection.
- To facilitate
secretion
movt and
drainage

- Administer

- To liquefy

- Turn the patient q

2 hours
- Encourage
increase fluid intake

s to prevent
and/or

RATIONALE

-Normalized
body temp.
from 38.4- 36.
4C
-Patient is able
to identify
interventions
to prevent
and/or reduce
the risk of
infection
-Patient
minimize or

-Patient will
have
minimize or
totally be
free from
the risk of
infection

antimicrobial such
as cefuroxime as
indicated.
-Administer
Antipyretic drug as
ordered.

secretions
- Handwashing
is the primary
defense
against the
spread of
infection
- Given
prophylacticall
y to reduce
any possible
complications.
-To normalize
body
temperature.

totally be free
from the risk
of infection
-Goal Met