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    Ineffective Airway Clearance: Fowler's

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    Marissa Asim
    The patient reported difficulty breathing with a blocked nose and coughing. On examination, the patient showed restlessness and changes in respiratory rate and depth, rhinorrhea, and decreased breath sounds. The nursing diagnosis was ineffective airway clearance. The goal was for the patient to achieve and maintain a patent airway and normal respiratory status within one week. The plan was to assess breathing patterns, auscultate the lungs, monitor cough and secretions, position the patient, administer bronchodilators, encourage fluids and breathing exercises. The expected outcomes were for the patient to have clear breath sounds, optimal respiratory exchange, be able to self-administer medications, and cough up secretions through exercises to prevent exacerbations.

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    Ineffective Airway Clearance: Fowler's

    Uploaded by

    Marissa Asim
    25 views3 pages
    The patient reported difficulty breathing with a blocked nose and coughing. On examination, the patient showed restlessness and changes in respiratory rate and depth, rhinorrhea, and decreased breath sounds. The nursing diagnosis was ineffective airway clearance. The goal was for the patient to achieve and maintain a patent airway and normal respiratory status within one week. The plan was to assess breathing patterns, auscultate the lungs, monitor cough and secretions, position the patient, administer bronchodilators, encourage fluids and breathing exercises. The expected outcomes were for the patient to have clear breath sounds, optimal respiratory exchange, be able to self-administer medications, and cough up secretions through exercises to prevent exacerbations.

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    AP-rhidab.docx

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    The patient reported difficulty breathing with a blocked nose and coughing. On examination, the patient showed restlessness and changes in respiratory rate and depth, rhinorrhea, and decreased breath sounds. The nursing diagnosis was ineffective airway clearance. The goal was for the patient to achieve and maintain a patent airway and normal respiratory status within one week. The plan was to assess breathing patterns, auscultate the lungs, monitor cough and secretions, position the patient, administer bronchodilators, encourage fluids and breathing exercises. The expected outcomes were for the patient to have clear breath sounds, optimal respiratory exchange, be able to self-administer medications, and cough up secretions through exercises to prevent exacerbations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    25 views3 pages

    Ineffective Airway Clearance: Fowler's

    Uploaded by

    Marissa Asim
    The patient reported difficulty breathing with a blocked nose and coughing. On examination, the patient showed restlessness and changes in respiratory rate and depth, rhinorrhea, and decreased breath sounds. The nursing diagnosis was ineffective airway clearance. The goal was for the patient to achieve and maintain a patent airway and normal respiratory status within one week. The plan was to assess breathing patterns, auscultate the lungs, monitor cough and secretions, position the patient, administer bronchodilators, encourage fluids and breathing exercises. The expected outcomes were for the patient to have clear breath sounds, optimal respiratory exchange, be able to self-administer medications, and cough up secretions through exercises to prevent exacerbations.

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    ASSESSMENT NURSING PLANNING (WITH RATIONALE IMPLEMENTATION EVALUATION

    DIAGNOSI AND REFERENCE)


    S
    SUBJECTIVE CUES: GOAL OF CARE Assess past patterns of After 8 hours of nursing
    The patient verbalized After 1 week of sleep in normal environment: intervention the client
    that “Nahihirapan ako Ineffective nursing amount, bedtime rituals, has been able to:
    maghinga kase barado intervention the depth, length, positions, aids,
    ilong ko pati may client will and interfering agents. - Verbalized feel
    Airway
    ubo” I have a hard After 8 hours of nursing intervention - Assess respiratory status for of rested
    time to breath because the client will: rate, depth, ease, use of
    my nose is block and I Clearance accessory muscles, and work
    have coughs.  Patient will achieve the return of breathing - achieve and
    of and ability to maintain - Auscultate the lung fields for maintain a patent
    patent airways and respiratory the presence of wheezes, airway.
    OBJECTIVE CUES: status baselines. crackles (rales), rhonchi, or
    decreased breath sounds.
    Restlessness  Patient will achieve and
    - - Monitor patient for cough and
    noted maintain a patent airway. - achieve and
    production of sputum, noting
    amount, color, character, and maintain a patent
    Changes in  Patient will have clear breath
    -
    patient’s ability to expectorate airway.
    respiratory rate sounds to auscultation and will
    have respiratory status secretions, and the ability to
    and depth
    parameters with optimal air cough. - have clear breath
    - Rhinorrhea exchange. - Position patient in sounds to
    high Fowler’s or semi- auscultation and
    - Decreased  Patient will be compliant and Fowler’s position, if possible. will have
    breath sounds be able to accurately - Administer bronchodilators as respiratory status
    administer medications on a ordered
    - parameters with
    daily basis, preventing - Encourage fluids, up to 3-4 optimal air
    -V/S taken as follows exacerbations of the disease
    L/day unless contraindicated. exchange.
    T: 36.7 process.
    - Encourage deep breathing
    P: 70
     Patient will be able to cough exercises and coughing
    R: 17 exercises every 2 hours.
    up secretions and perform
    BP:120/90
    coughing and deep-breathing
    exercises.

    Rationale
    Changes may vary from minimal to
    extreme caused by bronchial swelling,
    increased mucus secretions caused by
    oversecretion of goblet cells and
    tracheobronchial infection, narrowing
    of air passageways, and presence of
    other disease states that complicates
    the current condition.

    Wheezing is caused by squeezing of


    air past the narrowed airways during
    expiration which is caused by
    bronchospasms, edema, and secretions
    obstructing the airways.Crackles or
    rales, result from consolidation of
    leukocytes and fibrin in the lung
    causing an infection or by fluid
    accumulation in the lungs.

    Mucus color from yellow to green


    may indicate the presence of infection.
    Tenacious, thick secretions require
    more effort and energy to expectorate
    through coughing, and may actually
    create an obstruction stasis that leads
    to infection and respiratory changes.

    https://nurseslabs.com/ineffective-
    airway-clearance/

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