University of Batangas
COLLEGE OF NURSING
Hilltop Road, Batangas City
NCM112 Medical Infectious Ward
BSN 3.3 Group 2 : Eje, Caryll Mae L., Fabrig, Jamaica Franchesca M., Faderogao, Sarah Mae F.
Assessment
Diagnosis
Subjective Data:
●​ “Nahihirapan akong
huminga at marami
akong plema,” as
verbalized by the
patient.
●​ Patient reports
difficulty breathing,
productive cough,
and chest discomfort
when coughing.
Objective Data:
●​ Temperature: 38.5°C
●​ HR: 104 bpm
●​ RR: 24 cpm
●​ BP: 128/78 mmHg
●​ O2 Sat: 92% on room
air oxygen therapy
initiated as prescribed
●​ Productive cough
with thick, yellowish
sputum
●​ Crackles heard on
bilateral lower lung
fields
●​ Dyspnea noted
●​ Use of accessory
muscles observed
●​ Patient appears
fatigued and restless
Ineffective Airway Clearance
related to increased
tracheobronchial secretions
as evidenced by productive
cough, thick yellowish
sputum, crackles, tachypnea,
dyspnea, and SpO₂ of 92% on
room air.
Planning
Short-Term Goal:
●​ Within 4 hours, the
patient will
demonstrate
improved airway
clearance as
evidenced by
effective coughing,
easier expectoration
of secretions,
decreased
adventitious breath
sounds, RR
decreased from 24
cpm toward 20 cpm
or below, and SpO₂
maintained at ≥94%
or within the
prescribed target
range.
Long-Term Goal:
●​ Within 24–48 hours,
the patient will
maintain a patent
airway as evidenced
by effective coughing
and deep breathing,
Intervention
Independent:
Monitor and document VS,
respiratory rate, depth,
rhythm, oxygen saturation,
and respiratory effort every 4
hours and as needed.
Rationale
Provides baseline data and
detects changes in respiratory
status.
Auscultate lung fields for
crackles, rhonchi, diminished
breath sounds, or other
abnormal sounds.
Identifies retained secretions and
changes in airway ventilation.
Position the patient in
Semi-Fowler’s to
High-Fowler’s position.
Promotes lung expansion and
improves ventilation.
Encourage coughing and
deep-breathing exercises
every 1–2 hours while
awake.
Helps mobilize and remove
retained respiratory secretions.
Encourage adequate oral
fluid intake if not
contraindicated.
Helps liquefy secretions, making
them easier to expectorate.
Reposition the patient every
2 hours and encourage
activity as tolerated.
Promotes secretion mobilization
and prevents complications
associated with prolonged
immobility.
Evaluation
After 4 hours:
PARTIALLY MET.
●​ Patient
demonstrates a
more effective
cough and is able
to expectorate
thick sputum. SpO₂
increased from
92% to 94% with
prescribed oxygen
therapy, and RR
decreased from 24
to 21 cpm.
However, crackles
and mild dyspnea
are still present.
After 24–48 hours: MET.
●​ After 24–48 hours
of continued
interventions, the
patient maintains a
patent airway,
demonstrates
effective coughing
and
University of Batangas
COLLEGE OF NURSING
Hilltop Road, Batangas City
decreased respiratory
secretions, improved
breath sounds,
reduced dyspnea,
and SpO₂ of ≥95%
Encourage the patient to
expectorate secretions
rather than swallow them
and observe the color,
amount, and consistency of
sputum.
Dependent:
Administer oxygen therapy
as prescribed and monitor
response.
Provides information regarding
the progression or resolution of
infection.
Improves oxygenation in patients
experiencing hypoxemia.
Administer prescribed
antibiotics, bronchodilators,
mucolytics, antipyretics, and
other medications.
Treats the underlying infection
and helps relieve respiratory
symptoms.
Collect sputum specimen for
culture and sensitivity as
ordered.
Helps identify the causative
organism and guides
antimicrobial therapy.
Collaborative:
Collaborate with the
respiratory therapist for
nebulization and other
airway-clearance measures
as indicated.
Collaborate with the
physician regarding
persistent hypoxemia,
increasing respiratory
distress, or worsening lung
sounds.
Provides additional
airway-clearance and respiratory
treatments.
Promotes timely intervention if
the patient's condition
deteriorates.
deep-breathing
techniques, reports
decreased difficulty
breathing, has
reduced
respiratory
secretions, and
maintains SpO₂ of
≥95%
University of Batangas
COLLEGE OF NURSING
Hilltop Road, Batangas City