Asilo, Rosette Justine D.
BSN3Y2-1
NCMB312 LEC: M1 – CU3
1.Give the rationale for each of the following nursing interventions and selectedactivities for
the nursing care plan for ineffective airway clearance: (20pts)
INTERVENTIONS
1. Encourage the client to take several deep
breaths
2. Encourage the client to take a deep breath,
hold for 2 seconds, and cough two or three
times in succession
3. Encourage use of incentive spirometry, as
appropriate
4. Promote systemic fluid hydration, as
appropriate
5. Monitor rate, rhythm, depth, and effort of
respirations
6. Note chest movement, watching for
symmetry, use of accessory muscles, and
supraclavicular and intercostal
7. Auscultate lung sounds after treatments to
note result
8. Monitor client’s respiratory secretions
9. Monitor client’s ability to cough effectively
10. Monitor for increased restlessness,
anxiety, and air hunger
RATIONALE
Deep breathing promotes oxygenation
before controlled coughing.
Controlled coughing is accomplished by
closure of the glottis and the explosive
expulsion of air from the lungs by the work of
abdominal and chest muscles.
Breathing exercise help maximize ventilation.
Adequate fluid intake enhances liquefaction
of pulmonary secretions and facilities
expectoration of mucus
To provide a basis for evaluating adequacy of
ventilation
Presence of nasal flaring and use of accessory
muscles of respiration may occur in response
to ineffective ventilation.
Assists in evaluating prescribed treatments
and individual outcomes.
People with pneumonia commonly produce
rust-colored, purulent sputum.
Respiratory tract infections alter the amount
and character of secretions. An ineffective
cough compromises airway clearance and
prevents mucus from being expelled.
This clinical manifestations would be early
indicators of hypoxia.
2.Matching. Match the following concepts with each other. Write the letter only. Use
CAPITAL letters. (2 points each)

ANSWER COLUMN A COLUMN B

1. Tracheostomy A. Upper airway
obstruction, upper airway
bleeding, inability to
clear lower airway
E secretions, laryngeal or
tracheal fracture, airway
burns, need for continuous
ventilation, decreased LOC
with inability to protect
airway
2. Oxygen Therapy B. Nasal cannula, face mask,
B non-rebreather, partial non-
rebreather, venture mask,
face tent
3. Assessments for need to C. Reduced oxygen in the
H suction blood characterized by a low
PO2 or Sa02
4. Hypoxemia D. Percussions over
congested areas can
C mechanically dislodge
tenacious secretions from
the bronchial walls
5. Incentive Spirometry E. Surgical opening into the
F trachea with the creation of a
stoma
6. Tracheostomy Precautions F. Improve pulmonary
ventilation, counteract the
effects of
anesthesia/hypoventilation,
G loosen respiratory
secretions, facilitate
respiratory gaseous
exchange, expand collapsed
alveoli
7. Indications Tracheostomy G. Keep duplicate tract
A tube with obturator at
bedside, keep foreign
objects such as aerosols
 and powders away from
trach, provide humidified
air and 02, keep the
stomata dry, good oral and
nasal hygiene, medical/
surgical asepsis
8. Chest Percussion H. Restlessness, gurgling
sounds during respiration,
adventitious breath sounds
D when chest is auscultated,
change in mental status, skin
color, rate and pattern of
respiration, pulse rate and
rhythm