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>Crackles heard Mechanisms that exist and above) >Note for changes in HR, BP, >Increased work of breathing can teaching the performed
upon in the lower and temperature. lead to tachycardia and patient will DBE and 3
auscultation on bronchioles and hypertension. Retained secretions perform DBE and coughing
the lung fields alveoli to maintain the or atelectasis may be a sign of an identify 3 exercises
>expectorates patency of the airway LTO: existing infection or inflammatory coughing
whitish phlegm include the >After 3 days of nursing process manifested by a fever or exercises
>No nasal flaring mucociliary system, interventions Patient will increased temperature Partially met if the
> no use of macrophages, and the maintain clear, open patient will
accessory lymphatics. Also, airways as evidence by >Note cough for efficacy and >Coughing is a mechanism for perform DBE and
muscles anesthesia and normal breath sounds, productivity clearing secretions. An ineffective identify 1-2
>no chest dehydration can alter normal rate and depth of cough compromises airway coughing
indrawing the function of the respirations, and ability to clearance and prevents mucus from exercises
>Not cyanotic mucociliary system. effectively cough up being expelled. Respiratory muscle Not met if the
Thus, increased secretions after treatments fatigue, severe bronchospasm, or patient does not
production of and deep breaths. thick and tenacious secretions are do DBE and not
secretions in possible causes of ineffective cough. identify any
conditions such as coughing exercise
pneumonia and >Unusual appearance of secretions
bronchitis can oppress may be a result of infection, STO 3 Fully met
these mechanisms. >After 3 day of nursing >Note presence of bronchitis, chronic smoking, or Fully met if after 5 patient
intervention ,the client will sputum; evaluate its other condition. A discolored minutes Soriano
be able to expectorate quality, color, amount, sputum is a sign of infection; an The patient identified 3
>Ineffective Airway
retained secretions and odor, and consistency. odor may be present. Dehydration identifies 3 alterations
Clearance can be an
maintain normal breathing may be present if patient has alterations in in lifestyle
acute (e.g.,
measured by SPo2, RR, labored breathing with thick, lifestlyle and daily and daily
postoperative
depth and rhythm tenacious secretions that increase activities activities
recovery) or chronic
airway resistance. Partially met if the
(e.g., CVA or spinal
patient identies 1-
cord injury) problem.
>Pulse oximetry is used to detect 2 alterations
High-risk for
>Use pulse oximetry to changes in oxygenation. Oxygen Not met if the
ineffective airway
monitor oxygen saturation should be maintained at patient does not
clearance are the aged
saturation; assess 90% or greater. Alteration in ABGS identify anything
individuals who have
arterial blood gases may result in increased pulmonary
an increased incidence
(ABGs) secretions and respiratory fatigue. STO 4 Partially
of emphysema and a
Fully met if After 2 met, patient
higher prevalence of
>The most convenient way to days of nursing soriano’s
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia
chronic cough or >Teach the patient the proper remove most secretions is intervention the oxygen
sputum production. ways of coughing and coughing. So it is necessary to assist patient will have saturation
breathing. (e.g., take a the patient during this activity. normal range in is now
>There is a wide range deep breath, hold for Deep breathing, on the other hand, Oxygen saturation lingering at
of airway clearance 2 seconds, and cough promotes oxygenation before (93% and above) 90-91%
interventions that two or three times in controlled coughing. Partially met if the
nurses can choose succession). patients oxygen
from when they are >The proper sitting position and saturation
teaching the patients >Educate the patient in the splinting of the abdomen promote increases to 90%
and family members following: effective coughing by increasing to 92% or
the strategies of Optimal positioning (sitting abdominal pressure and upward increases from
secretion removal. In position) diaphragmatic movement. any range higher
general, these Use of pillow or hand splints Controlled coughing methods help than former SPo2
interventions are done when coughing mobilize secretions from smaller Not met if the
to maintain a patent Use of abdominal muscles for airways to larger airways because patients SPo2
airway, improve more forceful cough the coughing is done at varying decreased or
comfort and ease of Use of quad and huff times. Ambulation promotes lung remained the
breathing, improve techniques expansion, mobilizes secretions, same
pulmonary ventilation Use of incentive spirometry and lessens atelectasis.
and oxygenation, and Importance of ambulation LTO: Partially
to prevent risks and frequent position Criteria: met patient
associated with changes Fully met if after 3 Soriano still
oxygenation problems. >Upright position limits abdominal days of nursing has
>Position the patient upright contents from pushing upward and interventions abnormal
if tolerated. Regularly inhibiting lung expansion. This Patient will breath
>Pneumonia is an
check the patient’s position promotes better lung maintain clear, sounds
infection in one or
position to prevent expansion and improved air open airways as (crackles),
both lungs. It can be
sliding down in bed. exchange. evidence by and
caused by bacteria,
normal breath irregular
viruses, or fungi.
sounds, normal respiration
Bacterial pneumonia is
rate and depth of but is able
the most common type
respirations, and to cough
in adults.
ability to effectively
effectively cough and
>Pneumonia causes up secretions after expectorate
inflammation in the air treatments and secretions
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia
breathing
Not met if the
patient does not
improve at any
factor all
References:
Healthline (n.d.)all about pneumonia and how to treat it effectively, Retrieved on 11/03/2017, from https://www.healthline.com/health/pneumonia
Scribd (n.d.) NCP ineffective airway clearance, Retrieved on 11/03/2017, from https://www.scribd.com/doc/36791581/NCP-Ineffective-Airway-Clearance