YEAR & SECTION: BSN 4-C

GROUP: 12
NURSING CARE PLAN – INEFFECTIVE AIRWAY CLEARANCE
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Airway After 24 hours of  Assess the - Maintaining a patent Goal met.
“nahihirapan akong Clearance related to nursing intervention, airway for airway is always the
humihinga at obstructed airway patency. first priority, After 24 hours of
sumasakit ang from retained  Patient will especially in cases nursing
dibdib ko kapag ako secretions as maintain a like trauma, acute intervention,
ay uubo” as evidenced by patent airway neurological
verbalized by the shortness of breath as evidenced decompensation, or  Patient
client by clear cardiac arrest. demonstrates
breath a patent
sounds, - Auscultation helps airway as
Objective: oxygen  Auscultate the nurse assess the evidenced
BP: 120/80 saturation lungs for the flow of air through by clear
PR: 95 bpm within presence of the bronchial tree breath
RR: 15 normal normal or and evaluate the sounds,
Temp: 36.5 limits, and adventitious presence of fluid or oxygen
SpO2: 92% the ability to breath solid obstruction in saturation
cough to sounds. the lung. within
 (+) crackles clear normal
sound secretions - A change in the limits, and
 thick usual respiration the ability to
yellowish may mean cough to
sputum  Assess respiratory clear
respirations compromise. secretions
  Teach the - The most
client the convenient way to
proper ways remove most
of coughing secretions is by
and breathing coughing

 Note for - Increased work of

changes in breathing can lead to
HR, BP, and tachycardia and
temperature hypertension.

 Position the - This position

client upright promotes better lung
if tolerated. expansion and
improved air
exchange.

 Maintain - Oxygen therapy is

humidified the administration of
oxygen as oxygen at a
prescribed. concentration
greater than that
found in the
environmental
atmosphere.

NURSING CARE PLAN – INEFFECTIVE BREATHING PATTERN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Breathing After 4 hours of  Assess the - The After 4 hours of
“Nahihirapan akong Pattern related to nursing intervention, ability to incapability to nursing intervention,
huminga dahil sa airway obstruction as mobilize mobilize
ubong kong may evidenced by  The client secretions. secretions  The client
plema” as verbalized shortness of breath maintains an may demonstrates
by the client and retained effective contribute to a effective
secretions breathing change in breathing
pattern, as breathing pattern, as
Objective: evidenced by patterns. evidenced by
BP: 110/70 relaxed relaxed
PR: 96 bpm breathing at a  Observe the - These may be breathing at a
RR: 15 normal rate presence of indicative of a normal rate
Temp: 36.2 and depth and sputum for cause for the and depth and
SpO2: 90% the absence of amount, color, alteration in the absence of
dyspnea. and breathing dyspnea.
 pH: 7.32  The client’s consistency. patterns.  The client’s
 PaO2: 56 respiratory respiratory
mmHg rate remains  Auscultate - This is to rate remains
 PaCO2: 60 within breath sounds detect within
mmHg established at least every decreased or established
 HCO3-: 28 limits. four hours. adventitious limits.
mEq/L  The client’s breath sounds.  The client’s
ABG levels ABG levels
 (+) crackles return to and  Place the - A sitting return to and
sound remain within client with position remain within
established proper body permits established
 Thick- limits. alignment for maximum limits.
yellowish  The client maximum lung  The client
sputum indicates, breathing excursion and indicates,
either pattern. chest either
verbally or expansion. verbally or
through through
behavior,  Maintain a - Encouraging behavior,
feeling clear airway. the client to feeling
comfortable mobilize their comfortable
when own when
breathing. secretions via breathing
effective
coughing
facilitates
adequate
clearance of
secretions.

 Instruct the - Adequate

client to hydration
increase fluid helps to thin
intake as the mucus in
tolerated and the
as indicated. respiratory
tract.

 Assess ABG - This monitors

levels oxygenation
according to and
facility policy. ventilation
status.
 Encourage
sustained - These
deep breaths techniques
promote deep
inspiration,
which
increases
oxygenation
 and prevents
atelectasis
 Stay with the
client during - This will
acute reduce the
episodes of client’s
respiratory anxiety,
distress. thereby
reducing
oxygen
demand.

DRUG STUDY – BENZONATATE

DRUG NAME INDICATION/ DRUG ADVERSE SPECIAL CONTRAINDICATIO NURSING
DOSAGE ACTION REACTION PRECAUTION N CONSIDERATION
Brand name: a non-narcotic Benzonatate is CNS: Sedation, Severe -Contraindicated with  Assess
Tessalon oral antitussive a local headache, mild hypersensitivity allergy to benzonatate or allergy to
drug used to anesthetic dizziness, reactions related benzonatate
Generic name: suppress drug that acts hallucinations, (bronchospasm, compounds(tetracaine); (tetracaine);
Benzonatate coughing. peripherally nasal cardiovascular lactation lactation,
by congestion, collapse) were -Use cautiously with pregnancy
Classification: anesthetizing sensation of reported with pregnancy  Assess nasal
Antitussives and reducing burning in the therapy (possibly mucus
the activity of eyes. related to membranes;
vagal stretch Dermatologic: sucking or skin color,
receptors or Pruritus, skin chewing the lesions;
nerve fibers eruptions capsule) orientation,
located in the GI: affect;
respiratory Constipation, adventitious
passages, nausea, GI sounds
lungs, and upset
pleura.

DRUG STUDY - MUCINEX

DRUG NAME INDICATION/ DRUG ADVERSE SPEACIAL CONTRAINDICATIO NURSING
DOSAGE ACTION REACTION PRECAUTION N CONSIDERATION
Brand name: Oral Guaifenesin Endocrine Patient with Children <6 years.  Assess
Mucinex Cough acts as an disorders: persistent or allergy to
expectorant Hypouricemia. chronic cough granisetron,
Generic name: Adult: As by increasing (as seen with pregnancy,
Guaifenesin conventional the effective Gastrointestinal asthma, lactation,
preparation: hydration of disorders: emphysema, liver or renal
Classification: 200-400 mg 4 the Abdominal pain, chronic impairment,
Expectorants hourly. As respiratory diarrhea, nausea, bronchitis, colitis.
extended-release gland thereby vomiting. smoking), cough  Assess for
tab: 600-1,200 increasing the accompanied by orientation,
mg 12 hourly. volume and Nervous system excessive reflexes,
Max: 2,400 mg reducing the disorders: phlegm, affect, blood
daily. viscosity of Dizziness, porphyria. pressure,
Child: 6-12 tenacious drowsiness, Severe hepatic bowel sounds
years 100 mg bronchial headache. and renal
four times daily. secretions, impairment.
Max: 400 mg thus Skin and Children.
daily. Max facilitating its subcutaneous Treatment with a
treatment removal by tissue disorders: cough and cold
duration: 5 days; natural Rash. medicine in
≥12 years Same clearance children
as adult dose. processes. (especially above
6 years old)
should be
considered
carefully due to
potential risks
and limited
evidence on
efficacy.
Pregnancy and
lactation.
 DRUG STUDY – FLUIMICIL
DRUG INDICATION/ DRUG ADVERSE SPECIAL CONTRAINDICATION NURSING
NAME DOSAGE ACTION EFFECTS PRECAUTION CONSIDERATION
Brand name: Acute & intense Hypersensitivity Asthmatic Hypersensitivity. Childn  Assess for
Acetylcysteine chronic resp fluidifying reactions patients. Patients’ <2 yr. Effervescent hypersensitivity
tract infections action, including w/ history of tab/Granules for oral soln to
Generic w/ abundant through its anaphylactic peptic ulceration. Phenylketonurics. acetylcysteine,
name: mucus free shock, Discontinue if asthma,
Fluimucil secretions due sulfhydryl anaphylactic/ bronchospasm antidotal use:
to acute group, on anaphylactoid occurs in patients Esophageal
Classification: bronchitis, mucoid or reaction, w/ bronchial varices, peptic
Mucolytics chronic mucopurulent bronchospasm, asthma. Caution ulcer
bronchitis & its secretions by angioedema, in patients’ w/  Assess for
exacerbations, clearing the rash & pruritus. histamine weight, temp,
pulmonary disulfide Inhalant intolerance skin color,
emphysema, bonds in Rhinitis, during long-term lesions, BP, PR,
mucoviscidosis glycoprotein stomatitis. treatment. Do not adventitious
& aggregates. mix w/ other sounds, bowel
bronchiectasis. medication. sounds, liver
palpation
Effervescent
tab Adult 600
mg daily
(preferably in
the evening).
Granules for
oral soln Adult
200 mg bid-tid.
Childn 100 mg
bid-qid
according to
age.

Duration or
treatment: 5-10
days in acute
phase. May be
continued for
several mth in
chronic state.

It is
recommended
to dilute IV inj
w/ 0.9% NaCl
soln or a 5%
glucose soln.