Short Term Goal After 4 hours of nursingintervention, airwaypatency will bemaintained,secretions will bereadilyexpectorated andthere will be signsof reduction

incongestion

Objectives That within 8 span of care, our patient will be able to improve airway clearance as manifested by: a. cough effectively and expectorate secretions b. clear breath sounds upon auscultation c. RR with in normal range of 16-20 bpm Interventions 1. Auscultate breath sound. Note adventitious breath sounds. some degree of bronchospasm is present in obstructions in airway and may or may not be manifested in adventitious breath sounds. 2. Reassess or monitor respiratory rate tachypnea is usually present to some degree and may be pronounced on admission or during stress/ concurrent acute infectious process. Respiration may be shallow and rapid, with prolonged expiration in comparison to inspiration. 3. Note presence/ degree of dyspnea respiratory dysfunction is variable depending on the underlying process. 4. Place patient in Moderate high Back Rest. elevation of the head of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms or legs with pillows helps reduce muscle fatigue and can aid chest expansion. 5. Keep environmental pollution to a minimum like dust, smoke and feather pillows. Precipitators of allergic type of respiratory reactions that can trigger/ exacerbate onset of acute episode.

6.Observe characteristics of cough and assist with measure to improve effectiveness of cough effort. Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head down position after chest precaution. 7. Encourage deep breathing exercise Provides patient in some means to cope with/ control dyspnea and reduce air trapping. 8. Administer medications (e.g. bronchodilators) helps expectorate secretions. 9. Provide fluids within individual capacity. helps liquefy secretions, enhancing experctoraion Evaluation The patient was able to cough out secretions. RR of 19 within the normal range.

Assess respiratory rate, rhythm, and depth respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties 2. Position patient with proper body alignment for optimal breathing pattern if not contraindicated, a sitting position allows for good lung excursion and chest expansion 3. Assess skin color and temperature Cyanosis occurs when at least 5g of hemoglobin is desaturated. Cool pale skin may be secondary to a compensatory/vasoconstictive response to hypoxemia 4. Assess nutritional status Malnutrition may result in premature development of respiratory failure because it reduces respiratory distress mass and strength. Overfeeding increases production of CO2, which increases respiratory drive and respiratory muscle fatigue. 5. Encourage sustained deep breaths by asking patient to yawn.

 to promote deep inspiration 6. Provide reassurance and allay anxiety by staying with patient during acute episodes of
respiratory distress

air hunger can produce an extremely anxious state 7. Teach patient appropriate breathing, coughing and splinting techniques to facilitate adequate clearance of secretions