ASSESMENT DIAGNOSIS SCIENTIFICEXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“inuubo p rin sya” as verbalized by the grandmother.

Objective:- received awake lying on bed ĉ ongoing IVF of #6 D5IMB iL @ 950cc remaining level to run for 12o, infusing well @ left hand - conscious and coherent- ĉ productive cough- ĉ good skin turgor-ĉ good capillary refill in 2-3 secs- s respiratory distress (RR: 26 CPM)- on HAD- ĉ good appetite, consumed all of the food served- ambulatory - afebrile (36.7 oC)

Ineffective airway clearance

r/t retained bronchial secretions

Maintaining a patent airway is

vital to life. Coughing is the

main mechanism for clearing the

airway. However, the cough may be ineffective in both

normal and disease states secondary to

factors such as pain from surgical incisions/ trauma,

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

lymphatic. Factors such as anesthesia and dehydration can

Within the 8˚ shift, the client will be able to demonstrate behaviors to improve clear

airway by expectoration of

retained secretions.

- establish rapport

- position the patient comfortably- monitor vital signs

- elevate head of bed

- Auscultate lungs for presence of normal or adventitious breath sounds

- Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, and position for breathing- Assess cough for effectiveness and productivity

- to facilitate cooperation as well as to gain pt’s trust- to promote comfort- to note any significant changes that can affect the pt’s condition- These promote better lung expansion and improved air exchange - These may indicate presence of mucus plug or other major airway obstruction - Abnormality indicates respiratory compromise

- Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe

Goal partially met. After the shift, the client

was able to demonstrate behaviors to

improve clear airway but

wasn’t able to expectorate

retained secretions.

affect function of the mucociliary

system. Likewise, conditions that

cause increased production of

secretions (e.g., pneumonia,

bronchitis, and chemical irritants) can overtax these

mechanisms. Ineffective airway clearance can be

an acute (e.g., postoperative recovery) or

chronic (e.g., from cerebrovascular

accident [CVA] or spinal cord injury)

problem.

- Assist patient in performing coughing and breathing maneuvers- encourage increase oral fluid intake

- Instruct patient in the following:

Optimal positioning (sitting position)

Use of abdominal muscles for more forceful cough

Importance of ambulation and frequent position changes

bronchospasm, or thick tenacious secretions).- These improve productivity of the cough

- Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing- Directed coughing techniques help mobilize secretions from smaller airways to larger airways. The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal pressure and upward diaphragmatic movement.

DRUG STUDYBRAND NAME

GENERIC NAME

DOSAGE ACTION INDICATION CONTRAINDICATION NURSINGCONSIDERATIONS

Ventolin Expectorant

Salbutamol 5 ml, TID Stimulates beta-2 receptors of bronchioles by increasing levels of cAMP which relaxes smooth muscles to

produce bronchodilatation. Also

causes CNS stimulation, cardiac stimulation, increased diuresis,

skeletal muscle tremors, and increased gastric acid secretion. Longer

acting than isoproterenol.

Relief of bronchospasm in bronchial asthma, chronic bronchitis,

emphysema and other reversible, obstructive pulmonary diseases.

Also useful for treating bronchospasm in patients with co-

existing heart disease of hypertension.

Hypersensitivity to salbutamol, also to

atropine and its derivatives. Threatened abortion during the first

or second trimester. Cardiac arrhythmias

associated with tachycardia caused by digitalis intoxication.

Hypertrophic obstructive

cardiomyopathy or tachyarrhythmia. Thyrotoxicosis. Prevention of

premature labor associated with

toxemia of pregnancy or antepartum

Assess cardio-respiratory function; BP, heart rate and rhythm, and breath sounds. Determine history of previous medication (theophylline), and ability to self medicate to prevent additive. Monitor for evidence of allergic reactions and paradoxical bronchospasm.

hemorrhage. Lactation. Use of non-selective

beta-blockers.

BRAND NAME

GENERIC NAME

DOSAGE ACTION INDICATION CONTRAINDICATION NURSINGCONSIDERATIONS

Tergicef Cefixime 5 ml, TID Inhibits bacterial cell wall synthesis, rendering cell

wall osmotically unstable, leading to cell death.

Bronchitis, bronchiectasis with infection, secondary infections of chronic

respiratory tract diseases, pneumonia, otitis media, sinusitis.

Pyelonephritis, cystitis, gonococcal urethritis, cholecystitis. Scarlet

fever.

Hypersensitivity. History of shock due to any ingredient of this

product.

Assess patient’s previous reaction to penicillin or other cephalosporins. Cross-sensitivity between penicillin and cephalosporins is common. Assess patient for signs and symptoms of infection before and during treatment; fever, earache, characteristics of wounds, sputum, urine, stool, and WBC >10,000/mm3

Obtain C&S before beginning drug therapy to identify if correct

treatment has been initiated. Assess for allergic reactions. Assess renal function before and during therapy; urine output. BUN and creatinine.