Time and Date Focus D- Data A- Action R- Response

October 12, 2022 Ineffective Airway Clearance D - > Crackles are heard upon auscultation.
3:30 PM (SAMPLE > Presence of Edema
TIME)
A- > Auscultate lungs for presence of normal or adventitious breath
sounds. (Crackles)
> Monitor vital signs
> Elevate head of bed and change client's position every 2 hr.
> Perform nasotracheal suctioning as necessary, especially if
cough is ineffective.
> Instruct the proper technique in coughing, deep breathing, and
splinting

R - > Maintain clear, open airways as evidence by normal breath

sounds, normal rate and depth of respirations, and ability to
effectively cough up secretions after treatments and deep breaths.

> Identify and avoid specific factors that inhibit effective airway
clearance.

> Classify methods to enhance secretion removal.