Cues Subjective: >Laging basa ang likod nya as verbalized by the mother.

>ang hilig nya din kasing kumain ng ice candy as verbalized by the mother. >Naobserba han kong nahihirapan syang huminga kaya dinala ko agad sya sa ospital as verbalized by the mother. > She had her first asthma attack a day before she

Nursing Diagnosis Ineffective Airway Clearance related to secretions in the bronchi

Analysis Increased amount and viscosity of secretions and/or inability to clear secretions through the normal cough mechanism may lead to pooling of secretions in lower airways. Pooling of secretions leads to infection and inadequate gas exchange. (p229, Nettina, Manual of Nursing Practice)

Goals and Objectives Goal: After an 8-hour shift, the clients mucous secretions would be lessened.

Intervention a. Encourage deepbreathing and coughing exercises. b. Give expectoran t or bronchodila tors as ordered.
c. Increase

Rationale >To maximize effort.

Evaluation After 8 hours, the clients mucus secretions were lessened.

>Helps in aiding effective airway clearance.

fluid intake to at least 2000mL/da y within level f cardiac tolerance. d. Encourage or provide warm versus cold liquids as appropriate .

>To help liquefy secretions.

>To liquefy secretions more.

turned three (3) years old. > The patient experienced itchy throat and slight coughing without mucus on friday. Objectives: >Coughing with sputum >Difficulty in vocalizing >Wide-eyed Vital Signs: PR: 108 RR: 38 Temp.: 36.9 Objective: After 30 minutes, the client will be able to maintain adequate, patent airway. >Helps in e. Provide liquefying supplement secretions al for better humidificati and faster on if expectoratin needed. g the secretions. >To prevent aspiration into lungs.

f. Discourage use of oilbased products around the nose.

a. Position head midline with flexion appropriate for age or condition. b. Assist with appropriate

>To open or maintain open airway in at-rest or compromise d individual. >To identify causative or precipitating factors.

After 30 minutes, the client was able to maintain adequate, patent airway.

testing. c. Elevate head of the bed or change position in every two (2) hours. >To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of or ventilation to different lung segments. >This will compromise airway.

d. Monitor child for feeding intolerance, abdominal distention, and emotional stressors.

>Chemical irritants and e. Keep allergens can environmen increase t allergen mucus free. production and bonchospas m.

Sources: Nanda

Far Eastern University Institute of Nursing

Nursing Care Plan

Katherine Emm Glory E. Hao BSN-222