Nursing

Diagnosis
Etiology Goals and
Objectives
Nursing
Interventions
Rationale Evaluation
Ineffective
airway
clearance
related to
increased
mucous
production
evidenced by
harsh breath
sounds.
Cues:
-sunken eyes
-nasal flaring
-presence of
harsh breath
sounds.
-labored
breathing
-RR= 47cpm

Intermediate
Cause:
Lack of initiative
to promote a
conducive
environment
Immediate
Cause
!nfavorable
"nvironment
Root Cause:
Inhalation of
airborne
droplets of
viruses# bacteria
or fungi.
Health
Implication:
$learance of
secretions is a
common
problem in
patients who
e%perience
acute
&oals
'y the end of the
nurse(s shift. )he
patient will be able to
maintain his airway
patency
*b+ectives
! )he ,urse
will have her
conditions
assessed
!a ! -onitor for
signs of infection
from the
patient(s vital
signs.
!b. Review
laboratory
results like .'$
and other results
which can
indicate
!a! /n
increase in
temperature#
respiratory rate
or pulse rate can
indicate systemic
infection.
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!b. Increased
in blood results
especially .'$
may indicate a
systemic
infection
!a 1id the nurse
monitor for signs of
infection from the
patient(s vital signs.3
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If no .hy3
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!b 1id the nurse
reviewed the
laboratory results3
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respiratory tract
infections.
/lthough the
offending agent
is a ma+or
factor# the
degree of
severity of
ineffective
airway
clearance
depends on
many other
factors
pulmonary host
defenses#
presence of
underlying
pulmonary
disease# age#
lifestyle habits#
environments#
airway
clearance self-
management
skills# and time
of specific
treatment.
"! )he nurse
will have
positioned
the client
properly
systemic
infection.
"!a! "levate the
head of the bed6
change pposition
every two hours.
"!b 0osition
head midline with
fle%ion
appropriate for
the clients age.
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"!a 7or
ma%imum lung
e%pansion and
decrease the
pressure on the
diaphragm.
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"!b. )his is to
open or maintain
open airway of
the patient at
rest or
compromised
individual.
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"!a 1id the nurse
adhered to the facility
infection protocol in
taking care of a
wound.
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If no .hy3
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"!b 1id the nurse
e%amined the
patient(s skin3

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If no .hy3
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#! )he patients
secretions
will be
e%pelled
$! increase
water and
fluid intake#
appro%imatel
y 8299ml6day
#!a. "ncourage
deep breathing
and coughing
e%ercise.
#!b. "ncourage
the patient to
increase fluid
intake
$! 7orce fluids to
at least :299
ml6day as
tolerated by the
patient ;unless
contraindicated<.
*ffer warm#
rather than cold
fluids
#!a! )his is to
ma%imi=e the
patients effort.
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#!b! )his is to
help li>uefy the
patients
secretions
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$! fluids
;especially warm
li>uids< aid in
mobili=ation and
e%pectoration of
secretions.
;,/,1/ by
1oenges#.849#
:
nd
ed.<
#!a 1id the patient
do deep breathing
and coughing
e%ercise.
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If no .hy3
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#!a 1id the patient
increased fluid intake
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$! .as the client able
to increase water and
fluid intake#
appro%imately
:299ml6day3
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%! )he patient
will drink the
medicines
prescribed by
the physician

2. a *btain
specimen for
culture and
sensitivity
%! b &ive
antibiotics as
ordered by the
physician.
%! a Immediate
identification of
organism type by
growth stain
allows prompt
treatment.
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%! b!
/ntibiotics are
absorbed and
metaboli=ed
differently by
patientsA
effectiveness
must be
evaluated from
patient to patient.
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%!a 1id the nurse
*btain ?pecimen for
culture and
sensitivity3
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If no .hy3
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%!b 1id the nurse
gave the antibiotics
ordered by the
physician3
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If no .hy3
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%!c. ,otify the
physician if any
interventions are
unsuccessful or if
the current
condition of the
patient becomes
worse
%! c. 0atients
who re>uest pain
medications at
most fre>uent
intervals than
prescribed may
actually re>uire
higher doses or
more potent
analgesics.
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%!c 1id the nurse
notify the physician if
any interventions are
unsuccessful or if the
current condition of
the patient becomes
worse3
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If no .hy3
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