NURSING CARE PLAN Name of Patient: JB Age:46 y.o. Ward/Bed No.:FMSW 1 Attending Physician: Dr.

S Impression/Diagnosis: Atelectasis R lung; can’t rule out mass; t/c consolidation pneumonia, PTB 4 Nursing Interventions Independent Assess airway patency. Rationale Evaluation

Clustered Cues March 22,2011 No subjective cues:client unable to verbalize due to the presence of NG and ET tube. Difficulty of breathing Excessive secretions in airway Inability to expectorate secretions effectively. Presence of crackles,wheezing Use of mechanical

Nursing Diagnosis Ineffective airway clearance related to

Rationale Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Outcome criteria

The client will be able to display patent airway with reduced abnormal breath sounds ,absence of dyspnea ,diminished secretions

Obstruction may be caused by accumulation of secretions, mucous plugs, hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET tube. Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement and unobstructed airflow. Lower airway obstruction, such as pneumonia or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.

Evaluate chest movement and auscultate for bilateral breath sounds.

Monitor ET tube placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or repositioning tube.

The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax.

rhonchi. shallow respirations. and mobilization secretions to keep the airway clear. Auscultate lung fields. pulmonary edema. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. dehydration. as indicated. Elevate head of bed. change position frequently. local hemorrhage. and airway spasm or obstruction. Observe amount and character of sputum and aspirated secretions.Ventillator Assess rate and depth of respirations and chest movement. noting areas of decreased or absent airflow and adventitious breath sounds. and wheezes are heard on inspiration and expiration in response to fluid accumulation. Presence of thick. Monitor for signs of respiratory failure such as cyanosis and severe tachypnea. When pneumonia is severe. and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. thick secretions. Decreased airflow occurs in areas consolidated with fluid. Crackles. Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. or infection—that require correction or treatment. Investigate changes. . bloody. Keeping the head elevated lowers diaphragm. the client may require endotracheal intubation and mechanical ventilation to keep airways clear. such as crackles and wheezes. Tachypnea. or purulent sputum suggests development of secondary problems—for example. aeration of lung segments. promoting chest expansion. tenacious.

Name of Student: Clinical Instructor: . as indicated. Monitor serial chest x-rays and ABGs. Aids in reduction of bronchospasm and mobilization of secretions. Fluids are required to replace losses. for example mucolytic (acetylcystein) and bronchodilator (Salbutamol). schedules. Coordination of treatments. and oral intake reduces likelihood of vomiting with coughing and expectorations. Administer medications. Perform treatments between meals and limit fluids when appropriate. Stimulates cough or mechanically clears airway in client who is unable to do so. limiting duration of suction to 15 seconds or less. Suctioning should not be routine. and duration should be limited to reduce hazard of hypoxia. Follows progress and effects of disease process and therapeutic regimen. Choose appropriate suction catheter. Collaborative Assist with and monitor effects of nebulizer treatments. Facilitates liquefaction and removal of secretions.Suction as needed when client is experiencing respiratory distress. Provide supplemental fluids such as IV and humidified oxygen. and aid in mobilization of secretions. Suction intermittently. Suction catheter diameter should be less than 50% of the internal diameter of the ET or tracheostomy tube for prevention of hypoxia. including insensible. and facilitates necessary alterations in therapy.