CUES Subjective: naglaway-laway siya ganina tong ga kurog siya.

Moa na mura na siyag gi-sipon as verbalized by the parent

DIAGNOSIS Risk for ineffective airway clearance/breating pattern related retained secretions secondary to seizure episodes R- Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway due to after episode of grand mal seizure.

NURSING OBJECTIVE After my 1 hour span of care patient my patient will maintain airway patency as evidenced by: a. Absence of seizure activity b. noiseless respirations, clear breath sounds; clear, odorless secretions. c. Expectorate clear secretions

Objective: - history of seizure episode - nasal plugging of mucus due to colds

NURSING INTERVENTION 1. Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema) or absent breath sounds (severe asthma) Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult maintain effective airways, especially if client has impaired cough function, is very young or old, developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated. 3.Place in lying position on a flat surface during seizure attack; turn head to side during seizure activity. Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway. 4. Loosen clothing from neck, chest, and abdominal areas. R- Facilitates chest expansion, enhancing breathing 5. place in high back rest in absence of seizure episode

R- to promote lung expansion 6.Administer supplemental oxygen or bag ventilation, as needed postictally. R - May reduce cerebral hypoxia resulting from decreased circulation and oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in and out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists, such as foreign body or aspiration. 7. Suction (nasal/tracheal/oral) when indicated, using correct size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated patient is showing desaturation of oxygen by oximetry or ABGs 8. Give expectorants, anti-inflammatory agents, bronchodilators and mucolytic agents as ordered to relax smooth respiratory musculature, reduce airway edema and mobilize secretions 9. Encourage/provide warm versus cold liquids, as appropriate. Increase fluid intake to

at least 2000 to 3000 mL/day within level of cardiac tolerance (may require intravenous line). Improvement of hydration status can help liquefy secretions