1. Ineffective airway clearance related to increased production of secretions.
Goal: The client does not feel shortness of breath and no sputum.
Expected outcomes:
- Maintain a patent airway with breath sounds clean or clear.
- Shows behavior to improve airway clearance, for example: an effective cough.
- Assess the respiratory function, breath sounds, the speed of the rhythm.
- Assess a comfortable position for a client.
- Suggest to cough effectively.
- Collaboration: Provision mukolitik, Give the drug as an indication.
- Assist the breathing pattern changes.
- Breathing can facilitate the circulation in the body.
- Cough teach effectively so patients independently.
- To lower airway spasm.
- Lowering the mucosal edema and smooth muscle spasm.
Goal: The client can reach the normal temperature.
Expected outcomes:
- Normal body temperature (36.5 to 37.5 0C-0C)
- Give a warm compress or cold pack in accordance with the client's approval.
- Encourage clients to use clothing that is thin and absorbs perspiration.
- Dressing damp or wet with sweat that much.
- Give a thin blanket.
- Collaboration: Give antipyretics.
- Warm compresses help dilate the pores of the skin surface so as to accelerate heat dissipation.
- Clothing that is thin, does not hinder the body's heat loss.
- Clothes are damp / wet will cause inconvenience to the client.
- Thick blanket that will hinder the body's heat loss.
- Can help you lose body heat.
