ASSESSMENTNURSING DIAGNOSISNURSING OBJECTIVENURSING INTERVENTIONRATIONALE EVALUATIONObjective: Presence of Rhonchi productiveCough with whitish sputum V/S: T: 3!" CP: #$bpmR: $%bpm&P: ''%/% ine(ective )irw)*c+e)r)nce re+)ted toe,cessive- thic.enedmucous secretionsshort term: /fter 3% mins!ofnursing interventionsthe p)tient wi++: 0emonstr)teimprovedventi+)tion )nd)de1u)te o,*gen! /rteri)+ b+oodg)ses 2/&3s4within norm)+r)nge! 5o signs ofrespir)tor*distress!'! /ssess respir)tor*!r)te- depth! 5ote useof )ccessor* musc+es-pursed +ip bre)thing-6n)bi+it* to spe).!$! 7+ev)te he)d of thebed- )ssist p)tient)ssume position toe)se wor. ofbre)thing! 7ncour)gedeep s+ow or pursed+ip bre)thing )sindividu)++* to+er)tedor indic)ted!'!8sefu+ in ev)+u)tingthe degree orrespir)tor* distress)nd chronicit* of thedise)se process!$!O,*gen de+iver*m)* be improved b*upright position )ndbre)thing e,ercisesto decre)se )irw)*co++)pse- d*spne))nd wor. ofbre)thing!P)tient disp+)*improvedventi+)tion )ndfreefrom s*mptomsof respir)tor*distress!3! Routine+* monitor s.in)nd mucousmembr)ne co+or!"! 7ncour)gee,pector)tion ofsputum9 suction whenindic)ted!3!C*)nosis m)* beperipher)+ in n)i+beds or centr)+ in+ips or e)r+obes!0us.iness )ndcentr)+ c*)nosisindic)te )dv)ncedh*po,emi)!"!Thic.- ten)cious-copious secretions)re m)jor source ifine(ective )irw)*s!ASSEMENT NURSING DIAGNOSISOBJECTIVE NURSING INTERVENTIONRATIONALE EVALUATIONObjective: :&od* temper)ture)bove norm)+ r)nge 23!" c4:6ncre)se ;&C count:Presence of incre)se mucus production:Ris. for Spre)d of 6nfection RT St)sis of Secretions < 0ecre)sed Ci+i)r*/ction:/fter 3% mins of nursing intervention the pt! wi++::5orm)+i=e bod* temp! from 3!": 3>!3C:P)tient wi++ identif* interventionsto prevent)nd/or reduce the ris. of infection:?onitor vit)+ signs!:Review import)nce of bre)thing e,ercises- e(ective cough- fre1uent position ch)nges- )nd )de1u)te @uid int).e: Turn the p)tient 1 $ hours: 7ncour)ge incre)se @uid int).e:Stress the import)nce of h)ndw)shing: /dminister :Aor b)se+ine d)t): These )ctivities promote mobi+i=)tion )nd e,pector)tion of secretions to reduce the ris. of deve+oping pu+mon)r* infection!: To f)ci+it)te secretion movBt )nd dr)in)ge: To +i1uef* :/fter 3% mins of nursing intervention the pt! h)d::5orm)+i=ed bod* temp! from 3!": 3C! " C:P)tient is )b+eto identif* interventionsto prevent )nd/or reduce the ris. of infection:P)tient minimi=e or :P)tient wi++ h)ve minimi=e or tot)++* be free from the ris. of infection)ntimicrobi)+ such )s cefuro,ime )s indic)ted!:/dminister /ntip*retic drug )s ordered! secretions: D)ndw)shingis the prim)r* defense )g)inst the spre)d of infection: 3iven proph*+)ctic)++* to reduce )n* possib+e comp+ic)tions!:To norm)+i=e bod* temper)ture!tot)++* be free from the ris. of infection:3o)+ ?et