Some of the nursing diagnosis based on the above assessment can be listed below:
A. Ineffective airway clearance related to excessive secretions
B. Ineffective breathing pattern related to decreased lung expansion
C. Risk for aspiration
D. Disturbed sleeping pattern related to fragmented sleep
E. Deficient knowledge related to lack of exposure to previous knowledge
1. Nursing diagnosis: Ineffective airway clearance related to excessive secretions
Defining characteristics
• Tachypnea, dyspnea
• Abnormal breath sounds
• Ineffective cough with or with cough
• Verbal report of inability for clear airway
Desired outcomes
• Respiratory rate, rhythm and depth return to baseline.
• Thin mucus produced while coughing.
• In auscultation, lungs are
A. Ineffective airway clearance related to excessive secretions
B. Ineffective breathing pattern related to decreased lung expansion
C. Risk for aspiration
D. Disturbed sleeping pattern related to fragmented sleep
E. Deficient knowledge related to lack of exposure to previous knowledge
1. Nursing diagnosis: Ineffective airway clearance related to excessive secretions
Defining characteristics
• Tachypnea, dyspnea
• Abnormal breath sounds
• Ineffective cough with or with cough
• Verbal report of inability for clear airway
Desired outcomes
• Respiratory rate, rhythm and depth return to baseline.
• Thin mucus produced while coughing.
• In auscultation, lungs are