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PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia

Assessment Explanation of the Objectives Interventions Rationale Criteria Actual


Problem Evaluation
Cues: Ineffective Airway STO: >Assess airway for patency. >Maintaining patent airway is STO: Partially
Clearance: Inability to always the first priority, especially Fully met if after 8 met
Nursing clear secretions or >After 8 hour of nursing in cases like trauma, acute hours of nursing because
diagnosis : obstructions from the interventions the client will neurological decompensation, or interventions the patient
Ineffective respiratory tract to be able to maintain airway cardiac arrest. client will have Soriano still
Airway maintain a clear patency by having clear breath has
Clearance airway. clear breath sounds Auscultate lungs for presence Abnormal breath sounds can be sounds crackles
related to of normal or adventitious heard as fluid and mucus Partially meet if upon
presence of >Breathing comes After 5 minutes of nursing breath sounds, as in the accumulate. This may indicate there are still auscultatio
secretions in the naturally and interventions patient would following: airway is obstructed. adventitious n on the
tracheobronchial effortlessly to identify the importance of breath sounds but lung fields
tree secondary to everyone. But there DBE and coughing exercises has been lessened but has
pneumonia are some who are and perform DBE and >Decreased or absent breath >These may indicate presence of a Not met if the been
incapable of keeping atleast 2-3 coughing sounds mucous plug or other major adventitious lessened
S their airways clear and exercises obstruction. breath sounds are compared
> Ok naman na their lungs healthy. the same or to the first
ako, gumagaling, Maintaining a patent >After 5 minutes of nursing >Wheezing >This may indicate partial airway worsened day
Pero medyo airway has always interventions the patient obstruction or resistance.
nahihirapan lang been vital to life. When will verbalize STO: Fully met
huminga problem concerning understanding of 3 danger >Coarse Crackles >This may indicate presence of Criteria patient
> "Hindi naman the airway happens, signs of pneumonia secretions along larger airways. Fully met if after 5 Soriano
ako nahihilo" coughing takes place, minutes the indentified
O which is the main >After 5 minutes of health patients identifies 3 danger
> On O2 mechanism for teaching the patient will >Assess respirations. >A change in the usual respiration 3 danger signs signs
inhalation at clearing it. However, identify 3 necessary Note quality, rate may mean respiratory compromise. Partially met if the
7LMP via coughing may not alterations in lifestyle and pattern, depth, flaring of An increase in respiratory rate and patients identifies
Facemask always be easy to daily activities to manage nostrils, dyspnea on rhythm may be a compensatory 2-3 danger signs
>RR of 25, everyone especially to pneumonia exertion, evidence of response to airway obstruction. Not met if the
shallow those patients with splinting, use of patient did not
>tachypnea incisions, trauma, accessory muscles, and identify anything
>SPo2: 87% respiratory muscle >after 2days of nursing position for breathing.
>Has episodes of fatigue, or interventions the patient STO 2 Fully met
productive neuromuscular will have normal ranges in Fully met if after 5 patient
Cough weakness. her oxygen saturation (93% minutes of health Soriano
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia

>Crackles heard Mechanisms that exist and above) >Note for changes in HR, BP, >Increased work of breathing can teaching the performed
upon in the lower and temperature. lead to tachycardia and patient will DBE and 3
auscultation on bronchioles and hypertension. Retained secretions perform DBE and coughing
the lung fields alveoli to maintain the or atelectasis may be a sign of an identify 3 exercises
>expectorates patency of the airway LTO: existing infection or inflammatory coughing
whitish phlegm include the >After 3 days of nursing process manifested by a fever or exercises
>No nasal flaring mucociliary system, interventions Patient will increased temperature Partially met if the
> no use of macrophages, and the maintain clear, open patient will
accessory lymphatics. Also, airways as evidence by >Note cough for efficacy and >Coughing is a mechanism for perform DBE and
muscles anesthesia and normal breath sounds, productivity clearing secretions. An ineffective identify 1-2
>no chest dehydration can alter normal rate and depth of cough compromises airway coughing
indrawing the function of the respirations, and ability to clearance and prevents mucus from exercises
>Not cyanotic mucociliary system. effectively cough up being expelled. Respiratory muscle Not met if the
Thus, increased secretions after treatments fatigue, severe bronchospasm, or patient does not
production of and deep breaths. thick and tenacious secretions are do DBE and not
secretions in possible causes of ineffective cough. identify any
conditions such as coughing exercise
pneumonia and >Unusual appearance of secretions
bronchitis can oppress may be a result of infection, STO 3 Fully met
these mechanisms. >After 3 day of nursing >Note presence of bronchitis, chronic smoking, or Fully met if after 5 patient
intervention ,the client will sputum; evaluate its other condition. A discolored minutes Soriano
be able to expectorate quality, color, amount, sputum is a sign of infection; an The patient identified 3
>Ineffective Airway
retained secretions and odor, and consistency. odor may be present. Dehydration identifies 3 alterations
Clearance can be an
maintain normal breathing may be present if patient has alterations in in lifestyle
acute (e.g.,
measured by SPo2, RR, labored breathing with thick, lifestlyle and daily and daily
postoperative
depth and rhythm tenacious secretions that increase activities activities
recovery) or chronic
airway resistance. Partially met if the
(e.g., CVA or spinal
patient identies 1-
cord injury) problem.
>Pulse oximetry is used to detect 2 alterations
High-risk for
>Use pulse oximetry to changes in oxygenation. Oxygen Not met if the
ineffective airway
monitor oxygen saturation should be maintained at patient does not
clearance are the aged
saturation; assess 90% or greater. Alteration in ABGS identify anything
individuals who have
arterial blood gases may result in increased pulmonary
an increased incidence
(ABGs) secretions and respiratory fatigue. STO 4 Partially
of emphysema and a
Fully met if After 2 met, patient
higher prevalence of
>The most convenient way to days of nursing soriano’s
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia

chronic cough or >Teach the patient the proper remove most secretions is intervention the oxygen
sputum production. ways of coughing and coughing. So it is necessary to assist patient will have saturation
breathing. (e.g., take a the patient during this activity. normal range in is now
>There is a wide range deep breath, hold for Deep breathing, on the other hand, Oxygen saturation lingering at
of airway clearance 2 seconds, and cough promotes oxygenation before (93% and above) 90-91%
interventions that two or three times in controlled coughing. Partially met if the
nurses can choose succession). patients oxygen
from when they are >The proper sitting position and saturation
teaching the patients >Educate the patient in the splinting of the abdomen promote increases to 90%
and family members following: effective coughing by increasing to 92% or
the strategies of Optimal positioning (sitting abdominal pressure and upward increases from
secretion removal. In position) diaphragmatic movement. any range higher
general, these Use of pillow or hand splints Controlled coughing methods help than former SPo2
interventions are done when coughing mobilize secretions from smaller Not met if the
to maintain a patent Use of abdominal muscles for airways to larger airways because patients SPo2
airway, improve more forceful cough the coughing is done at varying decreased or
comfort and ease of Use of quad and huff times. Ambulation promotes lung remained the
breathing, improve techniques expansion, mobilizes secretions, same
pulmonary ventilation Use of incentive spirometry and lessens atelectasis.
and oxygenation, and Importance of ambulation LTO: Partially
to prevent risks and frequent position Criteria: met patient
associated with changes Fully met if after 3 Soriano still
oxygenation problems. >Upright position limits abdominal days of nursing has
>Position the patient upright contents from pushing upward and interventions abnormal
if tolerated. Regularly inhibiting lung expansion. This Patient will breath
>Pneumonia is an
check the patient’s position promotes better lung maintain clear, sounds
infection in one or
position to prevent expansion and improved air open airways as (crackles),
both lungs. It can be
sliding down in bed. exchange. evidence by and
caused by bacteria,
normal breath irregular
viruses, or fungi.
sounds, normal respiration
Bacterial pneumonia is
rate and depth of but is able
the most common type
respirations, and to cough
in adults.
ability to effectively
effectively cough and
>Pneumonia causes up secretions after expectorate
inflammation in the air treatments and secretions
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia

sacs in your lungs, deep breaths. after


which are called treatments
alveoli. The alveoli fill Partially met if she and deep
with fluid or pus, has normal breath breaths
making it difficult to sounds, rate and
breathe. depth of
respirations but is
not able to
>Normally the lungs
effectively cough
are free from
up secretions after
secretions. Pneumonia
treatments and
bacteria are invading
deep breath
the lung
parenchymathus,
Not met if the
producing
patient does not
inflammatory process.
improve at all
And these responses
leading to filling of the
LTO:
alveolar sacs with
Fully met if after 3
exudates leading to
days of nursing Partially
consolidation. The
interventions the met
airway is narrowed
patient will because the
thus wheezes is being
be able to patient still
heard. DOB in some
expectorate has
cases
retained abnormal
secretions and Spo2, and
maintain normal RR but is
breathing able to
measured by expectorate
SPo2, RR, depth secretions
and rhythm
Partially met if the
patient is able to
expectorate the
phlegm but still
has abnormal
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia

breathing
Not met if the
patient does not
improve at any
factor all

References:

Healthline (n.d.)all about pneumonia and how to treat it effectively, Retrieved on 11/03/2017, from https://www.healthline.com/health/pneumonia

Nurseslabs (n.d.)Ineffective airway clearance, Retrieved on 11/03/2017 from https://nurseslabs.com/ineffective-airway-clearance/

Scribd (n.d.) NCP ineffective airway clearance, Retrieved on 11/03/2017, from https://www.scribd.com/doc/36791581/NCP-Ineffective-Airway-Clearance