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 muscle
retractions
7. Auscultate lung sounds after treatments to
note results
8. Monitor client’s respiratory secretions
9. Monitor client’s ability to cough
effectively
10. Monitor for increased restlessness,
anxiety, and air hunger
RATIONALE
It promotes oxygenation before controlled
coughing
This moves air down to the bottom areas of the
lungs. Band opens up the air passages and moves
the mucous out; coughing is also easier
This incentive spirometer is a hand-held breathing
exercise device to help the patient breathe deeply.
Adequate fluid intake enhances dissolving
of pulmonary secretions and facilitates
expectoration of mucus
Provides a basis for evaluating adequacy of
ventilation.
Presence of nasal erupting and utilization
of embellishment muscles of breaths may happen
in light of incapable ventilation.
It is important to distinguish normal respiratory
sounds from abnormal ones for example crackles,
wheezes, and pleural rub in order to make correct
diagnosis
Assists in evaluating prescribed treatments and
client outcomes
Respiratory tract infections alter the amount
and character of secretions. An ineffective
cough compromises airway clearance and
prevents mucus from being expelled
These clinical manifestations would be early
indicators of hypoxia