Nursing Diagnosis: Ineffective airway clearance related to inability to remove airway secretions secondary to disease process as manifested by difficulty

in breathing, increased respiratory rate and verbalization of Marigatan nak umanges ading . Nursing Inference Kochs disease can cause a wide range of effects in the lungs, ranging from a small patch of bronchopneumonia to diffuse intense inflammation, caseous necrosis, pleural effusion, and extensive fibrosis. Respiratory effects can range from mild dyspnea to profound respiratory distress. Accumulation of secretions and compromised airway can impair oxygenation of vital organs and tissues. Nursing Goal After 1 hour of rendering series of nursing interventions the client will be able to stabilize the respiratory rate within normal range as well as the respiratory rhythm and verbalization of Hanak marigatan umangesen ading . Nursing Intervention 1. Position the client on high back rest. To open/maintain airway and for lung expansion. 2. Monitor respiratory rate and rhythm. To assess respiratory distress 3. Encourage deep breathing and coughing exercise. To allow lung expansion to compensate for the decreased oxygen level in the lungs 4. Instruct client to increase oral fluid intake. To help liquefy mucus secretions 5. Perform suctioning as needed. To remove mucus secretions obstructing the airway 6. Administer oxygen as ordered. To provide additional oxygen to the client 7. Administer mucolytic, expectorant and antibiotics as ordered. To liquefy mucus secretions, expel the secretions that obstruct the airway and kill the bacteria. Nursing Evaluation After 1 hour of rendering series of nursing interventions the client was able to stabilize the respiratory rate within normal range as well as the respiratory rhythm and verbalization of Hanak marigatan umangesen ading .

Nursing Diagnosis Activity intolerance related to imbalance oxygen demand and supply as evidenced by reports of fatigue, weakness and exertional dyspnea.

Nursing Inference Frequent cough, sputum production and exertional dyspnea can cause fatigue.

Nursing Goal After 2-3 hours of rendering series of nursing interventions the client will be able to manifest absence of fatigue, weakness and exertional dyspnea.

Nursing Intervention 1. Encourage and provide for frequent rest periods. To conserve energy. 2. Plan activities of the client accordingly. To conserve energy 3. Administer oxygen as ordered. To provide additional oxygen to the client. 4. Assist client to identify appropriate coping behaviors. To promote sense of control and improves self-esteem.

Nursing Evaluation After 2-3 hours of rendering series of nursing interventions the client was able to manifest absence of fatigue, weakness and exertional dyspnea.