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    Maternal Midterm-W2

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    Jireh Vien Atienza
    The 11-month-old client is experiencing ineffective airway clearance possibly due to ineffective coughing as evidenced by adventitious lung sounds, cyanosis, and dyspnea. The nursing diagnosis is ineffective cough clearance related to an inability to clear mucus from the lungs and difficulty breathing. The short-term goals are to prevent cyanosis and hypoxia within 30 minutes of interventions. The long-term goal is optimized breathing after 1 week as seen by relaxed breathing patterns. Nursing interventions include assessing vital signs, skin color, cough effectiveness and lung sounds. Environmental changes and medications may also help the condition.

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    Maternal Midterm-W2

    Uploaded by

    Jireh Vien Atienza
    16 views2 pages
    The 11-month-old client is experiencing ineffective airway clearance possibly due to ineffective coughing as evidenced by adventitious lung sounds, cyanosis, and dyspnea. The nursing diagnosis is ineffective cough clearance related to an inability to clear mucus from the lungs and difficulty breathing. The short-term goals are to prevent cyanosis and hypoxia within 30 minutes of interventions. The long-term goal is optimized breathing after 1 week as seen by relaxed breathing patterns. Nursing interventions include assessing vital signs, skin color, cough effectiveness and lung sounds. Environmental changes and medications may also help the condition.

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    MATERNAL_MIDTERM-W2

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    The 11-month-old client is experiencing ineffective airway clearance possibly due to ineffective coughing as evidenced by adventitious lung sounds, cyanosis, and dyspnea. The nursing diagnosis is ineffective cough clearance related to an inability to clear mucus from the lungs and difficulty breathing. The short-term goals are to prevent cyanosis and hypoxia within 30 minutes of interventions. The long-term goal is optimized breathing after 1 week as seen by relaxed breathing patterns. Nursing interventions include assessing vital signs, skin color, cough effectiveness and lung sounds. Environmental changes and medications may also help the condition.

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    © All Rights Reserved
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    16 views2 pages

    Maternal Midterm-W2

    Uploaded by

    Jireh Vien Atienza
    The 11-month-old client is experiencing ineffective airway clearance possibly due to ineffective coughing as evidenced by adventitious lung sounds, cyanosis, and dyspnea. The nursing diagnosis is ineffective cough clearance related to an inability to clear mucus from the lungs and difficulty breathing. The short-term goals are to prevent cyanosis and hypoxia within 30 minutes of interventions. The long-term goal is optimized breathing after 1 week as seen by relaxed breathing patterns. Nursing interventions include assessing vital signs, skin color, cough effectiveness and lung sounds. Environmental changes and medications may also help the condition.

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    © All Rights Reserved
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    of 2

    TRINIDAD, SOPHIA MAE

    BSN 2C

    ASSESSMENT DIAGNOSIS NURSING OBJECTIVES NURSING RATIONALE EVALUATION


    ANALYSIS INTERVENTIONS
    “Napansin kong Ineffective airway Ineffective Cough SHORT TERM: - Assess vital signs, - The pattern and SHORT TERM:
    parang nahihirapan clearance may be especially respiratory pace of breathing
    sa paghinga ‘yung related to Hinders with airway After 30 minutes of rate, pulse rate, and may change as a After 30 minutes
    anak ko. Inuubo rin ineffective cough clearance and nursing oxygen saturation. signal to approaching of nursing
    siya.” As possibly evidenced inhibits mucus interventions, the respiratory distress. interventions, the
    verbalized by the by adventitious discharge. patient is unlikely patient is unlikely
    mother of the 11- lung sounds, to experience - Examine the color of - The presence of to experience
    month-old client. cyanosis, and Difficulty of cyanosis or any the skin, nails, and cyanosis suggests low cyanosis or any
    dyspnea. breathing other hypoxia- mouth. oxygen transport and other hypoxia-
    Objectives: related symptoms. insufficient tissue related symptoms.
    - Nasal flaring Shortage of oxygen oxygenation as a
    - Dyspnea LONG TERM: result of respiration. LONG TERM:
    - Tachypneic Cyanosis
    - Cyanosis After week of - Auscultate lungs - One of the most After week of
    - Lethargy nursing clinical nursing
    - Ineffective cough interventions, the manifestations is interventions, the
    - Wheezing sound client will continue wheezing, a melodic, client will
    of lungs to breathe in an high-pitched continue to
    optimized manner, whistling sound breathe in an
    as seen by their caused by airway optimized manner,
    relaxed breathing disturbance. as seen by their
    and regular relaxed breathing
    breathing patterns. - Determine how - Some of the causes and regular
    effective coughing is. of an unproductive breathing patterns.
    cough include acute
    bronchospasm, thick
    secretions, and
    exhaustion of the
    respiratory muscles.
    - Monitor results of - An x-ray of the
    chest x-ray chest can reveal
    whether
    inflammation,
    inflated lungs, or
    barotrauma have
    occurred.

    - Educate the mother to - To prevent


    control the client's exhaustion and boost
    activity schedule. effort in breathing
    properly, divide tasks
    into smaller portions
    and take rest breaks
    in between.

    - Eliminate sources of - Environmental


    environmental pollution changes have been
    demonstrated to
    lower important
    indoor pollution and
    allergen exposures.

    DEPENDENT:

    - Administer oxygen as - To substantially


    prescribed lessen difficulty of
    breathing

    - Appropriate - Helps open up the


    medications such as airways and ease the
    bronchodilator as lungs' muscles
    instructed by the
    physician.

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