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Published by konoha2214839

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Published by: konoha2214839 on Jul 01, 2010
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: Ineffective Airway clearance related to accumulation of secretions
After 4 days of nursing interventions, the patient will be able to maintain its airway patency as manifested by:a. Absence of adventitious breath sounds upon auscultationb. Decrease oxygen inhalation from 2-3 lpm to 1-2 lpm
a. After 8 hours of nursing interventions, the patient will demonstrate an increase in its fluid intake from 3-5 glasses per day to 5-7 glasses per day astoleratedb. After 8 hours of nursing interventions, the patient will verbalize a readily expectoration of secretions of at least 1 teaspoon per coughing episodec. After 8 hours of nursing interventions, the patient will demonstrate a decrease in coughing episodes from 6-8 coughing episodes pre shift to 4-6coughing episodes per shift
“I have cough but I can’t expectorate the phlegm”
- with vital signs of CR- 55 bpm, RR- 24 cpm and T°- 36.1°C- frequent unproductive coughing episodes noted- appears weak- with O2 inhalation of 2-3 lpm- crackles heard over lung fields- noted fluid intake of 3-5 glasses per day
Explanation of the problem
The patient has unproductive cough therefore secretions are retained inthe bronchi. The inability to expectorate out secretions causes it toaccumulate at the bronchi that now leads to an obstruction into therespiratory tract which causes the patient to experience ineffective airwayclearance.
Dx:-Assessed and recorded Vital Signs- Noted for physiological andpsychological factors that is relatedto ineffective airway clearance- Noted for coughing episodes andcharacteristic-Assessed hydration status bynoting fluid intakeTx:- Auscultated lung fields to notepresence of adventitious breathsounds- Assisted during nebulizatio andback tapping done- Elevated head of bed- V/S serve as baseline data andvalidates the autonomic responsesof the patient- Knowing the factors, we can knowthe underlying cause of the problemand in order for us to giveappropriate interventions- To determine the patient’s abilityto expectorate secretions tomaintain a patent airway- A person’s hydration status canbe determined by noting fluidintake. An increase in fluid intakemay help liquefy secretions for expectoration.- Presence of adventitious breathsounds indicates respiratorydistress and or accumulation of secretions- Nebulization and Back tappinghelps liquefy viscous secretions- This is to open or maintain anopen airwayGOAL/LTO fully met if the patientwill be able to:a. Demonstrate an absence of adventitious breath soundsb. Decrease oxygen inhalation from2-3 lpm to 1-2 lpmGOAL/LTO partially met if thepatient will only demonstrate one of the 2 given criteriaGOAL/LTO not met if the patient isnot able to demonstrate any of the2 given criteriaSTO fully met if the patient will beable to:a. Increase its fluid intake from 1Lto 1.5L per day as toleratedb. Verbalize a readily expectorationof secretions to at least 1 teaspoonper coughing episodec. Decrease in coughing episodesfrom 6-8 coughing episodes to 4-6coughing episodes per shiftSTO partially met if the patient isable to demonstrate only 2 out of 3of the above stated criteria

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