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    The nursing diagnosis was inefficient removal of airway obstructions due to build-up of mucus in the respiratory system. The goals of nursing intervention were to facilitate oxygen supply to cells and reduce mucus accumulation through expectoration and effective coughing. Interventions included monitoring vital signs and breathing patterns, positioning the patient upright, demonstrating proper coughing technique, advising activity and warm fluids, and administering ceftriaxone IV antibiotic and nebulized bronchodilators. The evaluation found that after 2 hours the patient was able to reduce mucus build-up through expectoration and perform effective coughing.

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    The nursing diagnosis was inefficient removal of airway obstructions due to build-up of mucus in the respiratory system. The goals of nursing intervention were to facilitate oxygen supply to cells and reduce mucus accumulation through expectoration and effective coughing. Interventions included monitoring vital signs and breathing patterns, positioning the patient upright, demonstrating proper coughing technique, advising activity and warm fluids, and administering ceftriaxone IV antibiotic and nebulized bronchodilators. The evaluation found that after 2 hours the patient was able to reduce mucus build-up through expectoration and perform effective coughing.

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    7 views4 pages

    Cough

    Uploaded by

    delavegajealou00
    The nursing diagnosis was inefficient removal of airway obstructions due to build-up of mucus in the respiratory system. The goals of nursing intervention were to facilitate oxygen supply to cells and reduce mucus accumulation through expectoration and effective coughing. Interventions included monitoring vital signs and breathing patterns, positioning the patient upright, demonstrating proper coughing technique, advising activity and warm fluids, and administering ceftriaxone IV antibiotic and nebulized bronchodilators. The evaluation found that after 2 hours the patient was able to reduce mucus build-up through expectoration and perform effective coughing.

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    of 4

    Maylien Ching BSN 3B

    METHODS OF OXYGEN ADMINISTRATION

    Venturi masks are designed to deliver constant


    Simple face masks (also called Hudson masks) are typically used FiO2 regardless of the patient’s respiratory rate and flow
    to treat mild to moderate hypoxia.The mask delivers 30 – 40% pattern (i.e. a fixed-performance device). They are
    O2 (flow rate 5-10 L/min). The mask is positioned over used to deliver oxygen to patients with chronic obstructive
    the patient’s.
    pulmonary disease (COPD) due to the risk of type 2
    respiratory failure. The Venturi mask fits over the
    patient’s nose and mouth like other face masks.

    Nasal cannulae (NC) are used for mild hypoxia, typically in non-
    acute situations. Nasal cannulae deliver 24 – 30% O2 (maximum
    flow rate of 4L/min). The NC tubing is placed around a patient’s An oxygen face tent is a unique device that delivers oxygen
    face with the prongs positioned at the nostrils. The NC tubing to patients who are unable to use standard oxygen delivery
    can be secured behind the patient’s head or around their ears. methods due to facial injuries or surgeries.

    Non-rebreather masks (also called reservoir masks) are used to


    treat patients with a significant degree of hypoxia (moderate to
    severe).Non-rebreather masks can deliver high
    FiO2 concentrations as the oxygen is inhaled from both the
    reservoir bag as well as the direct oxygen source.This mask
    delivers approximately 70% O2 when used with a 15L oxygen flow
    rate.The mask fits over the patient’s nose and mouth and can be
    secured to the face using elastic straps.
    Name: Mr. M.B Age: 66 years old

    Attending Physician: Dr. Buenaflor Sex: Male

    Cues Nursing Objectives Nursing Rationale Evaluation


    Diagnosis Intervention

    Subjective Data: Inefficient General objectives Independent: Goals Met


    “Gainubo ako ag ro removal of
    akong ubo hay may airway  To facilitate the -Established rapport -To gain trust and
    plema nga nalisdan obstructions maintenance of with patient cooperation to the After nursing
    ko ipaguwa” as due to the a supply client interventions, the
    verbalized by the build-up of of oxygen to all patient will be able to
    body -To serve as baseline data reduced mucus
    patient. mucus in the -Monitored vital
    respiratory cells. accumulation
    sign especially
    system, through expectoration,
    respiratory rate and
    Objective Data: resulting in performed
    Specific Objectives: oxygen
    challenges in -To determine if there are effective coughing
     RR-20 saturation.
    phlegm any changes in the exchange technique and spit
    After 2hours of
    expulsion. -Monitored the of gas. the phlegm.
     Non Productive rendering nursing care
    cough the patient will be able patient’s breathing
    to: pattern.
     thick sputum -To distinguish normal
    -Assessed breath respiratory
     restlessness  Reduce mucus sounds sounds from abnormal ones.
    accumulation
    -Put patient in an up -To relax the muscles that
    through
    right or high fowlers wrap around
    expectoration
    position your breathing tubes
     Perform (airways) allowing the tubes
    effective to become larger and easier
    couhing to to breath trough.
    expectorate
    mucus -Keep the head
    secretions. elevated
    It can help to drain phlegm
    from the
    sinuses and prevent it from
    pooling in
    the back of the throat.

    -Demonstrated the
    -Helps to remove mucus
    patient to do proper
    from airways,
    coughing technique.
    to prevent the spread of
    serious
    respiratory illnesses
    -Advised the patient
    to perform activity
    like splinting chest -To help make the cough
    and effective stronger and
    coughing. less painful

    -Instruct the patient


    to consume warm -To provide relief for a stuffy
    fluids such as soup nose and
    and tea to loosen phlegm

    Dependent
    - a treatment that provides
    Ceftriaxone 1g IV you with
    q8H supplemental oxygen.

    Ceftriaxone is a broad-
    spectrum
    cephalosporin antibiotic used
    for the treatment of
    bacterial infections in
    various locations, such as in
    the
    Salbutamol + respiratory tract,
    Ipratropium neb
    500mcg/2.5mg -Ipratropium bromide is an
    anticholinergic
    (parasympatholytic)
    agent which, based on
    animal studies,
    appears to inhibit vagally-
    mediated
    reflexes by antagonizing the
    action
    of acetylcholine, the
    transmitter agent
    released at the
    neuromuscular
    junctions in the lung.

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