NCP- INEFFECTIVE AIRWAY CLEARANCE PEDIA.docx

ASSESSMENT

Subjective: “Nahihirapang huminga ang anak ko at may kontingplema saya kung umuubo siya.” As verbalized by the patient’s mother. Objective: BP: 60/40 PR: 167 bpm Temp: 37.2°C RR: 71 cpm Tachypneac Dyspneac Tachycardiac With DOB and crackel sounds on left lung Change in respiratory rate and rhythm With series of productive cough

NURSING DIAGNOSIS

Ineffective airway clearance related to excessive mucus secondary to pneunonia

INFERENCE

PLANNING

Pneumonia is  After 8 hours hours of inflammation of the nursing inter terminal airways vention the patient and alveoli caused would be able to: by acute infection by various agents. Maintain airway Pneumonia can be patency divided into three groups: community Demonstrate reduction of acquired, hospital congestion with or nursing home breath sounds acquired clear, respirations (nosocomial), and noiseless, improve  pneumonia in an immunocompromis oxygen exchange. ed person.Causes include bacteria Display absence of (Streptococcus, tachypnea, Staphylococcus, dyspnea and Haemophilus tachycardia influenzae, Klebsiella, Legionella). Community  Acquired Pneumonia (CAD) is a disease a disease in which individuals who have not recently been hospitalized been hospitalized develop an infection an infection of the lungs. the lungs. It  It is an acute inflammatory condition that’s result from aspiration of

NURSING INTERVENTION

Independent: Elevate head of the bed/ change position every 2 hours and prn.

Monitor v/s signs especially respiratory rate, note for respiratory distress Monitor respirations and breath sounds, noting rate and sounds Evaluates client’s cough or gag reflex and swallowing ability

Suction naso/tracheal/oral prn

RATIONALE

To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation of different lung segment

To evaluate degree of compromise

EVALUATION

 After 8 hours hours of nursing inter vention the patient: Maintained airway patency Demonstrated reduction of congestion with breath sounds clear, respirations noiseless, improve oxygen exchange. Displayed absence of tachypnea, dyspnea and tachycardia The goal is met

Indicatives of respiratory distress and/or accumulation of secretions To determine ability to protect own airway

To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow

oropharyngeal secretions or stomach contents in the lungs.

or cough effectively Standby Oxygen at bedside Insert oral airway as needed

 Advice CPT to mother

Increase fluid intake to at least 2000ml/day within cardiac tolerance

Dependent: Give expectorants/bron chodolators as ordered

For emergency

To maintain anatomic position of tongue and natural airway, especially when tongue/ laryngeal edema or thick secretions may block airway Helps on secretion of excessive mucus Hydration can help liquefy viscous secretions and improve secretion clearance

 Aids in reduction of bronchospas m and mobilization of secretions.