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- The client reported difficulty breathing and objective findings included use of accessory muscles, dyspnea, and productive cough.
- The nursing diagnosis was ineffective airway clearance related to increased production of secretions due to chronic obstructive pulmonary disease (COPD).
- The goal was for the client to demonstrate behaviors to improve airway clearance such as coughing effectively and expectorating secretions after nursing interventions.
- The client reported difficulty breathing and objective findings included use of accessory muscles, dyspnea, and productive cough.
- The nursing diagnosis was ineffective airway clearance related to increased production of secretions due to chronic obstructive pulmonary disease (COPD).
- The goal was for the client to demonstrate behaviors to improve airway clearance such as coughing effectively and expectorating secretions after nursing interventions.
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- The client reported difficulty breathing and objective findings included use of accessory muscles, dyspnea, and productive cough.
- The nursing diagnosis was ineffective airway clearance related to increased production of secretions due to chronic obstructive pulmonary disease (COPD).
- The goal was for the client to demonstrate behaviors to improve airway clearance such as coughing effectively and expectorating secretions after nursing interventions.
Drepturi de autor:
Attribution Non-Commercial (BY-NC)
Formate disponibile
Descărcați ca DOC, PDF, TXT sau citiți online pe Scribd
DIAGNOSIS Subjective: Ineffective Chronic GOAL: “Nahihirapan airway obstructive ako clearance pulmonary After nursing • After nursing huminga” as related to disease interventions, intervention verbalized by increased (COPD) is a the client will s, the client the production of disease demonstrate was able to patient. secretions. characterized behaviors to demonstrate Objective: by airflow improve behaviors to • Use of limitation that airway improve accessory is not fully clearance. airway muscle. reversible. Air e.g. cough clearance. • Dyspnea flow limitation effectively e.g. cough • Productive is usually and effectively cough progressive expectorate and • V/S taken as and secretions. expectorate follows: associated secretions. T: 36.7 with an Objectives: Independent: • Elevation of P: 57 inflammatory • Positioning the • Assist patient the R: 25 response in client. to assume head of the Bp: 100/80 the lungs position of bed stimulated by comfort, e.g., facilitates irritants. elevate head respiratory Common of bed, function cause of encourage by use of COPD is patient to lean gravity. cigarette on overbed smoking, air table or sit on pollution, the edge of allergens and • Keeping the the bed. • Precipitator infections that client free of • Keep s of may also act pollution. environmental allergic type as irritants. pollution to a or minimum, respiratory e.g., dust, reactions that smoke and can feather trigger or pillows, exacerbate according to onset individual of acute situation episode. • Encouraging • Provides the • Encourage or patient importance assist with with some of pursed lip pursed lip means breathing breathing to cope or exercises. exercises. control dyspnea and reduce air trapping. • Observation • Coughing is of the client. • Observe most characteristics effective in an of cough like upright persistent or position or hacking or head down moist. Assist position with measures after chest to improve percussion. effectiveness of cough effort • Providing the client’s Dependent: • A variety of needed • Administer medications medication. medication as may prescribed by be used to the physician. decrease mucus and to improve respiration. • Providing the • Humidity client with • Provide helps the right supplemental reduce humidifier. humidification viscosity of like nebulizer. secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles