AUBREY ROSE A.

VIDON

BSN 3Y1 - 2

1. Give the rationale for each of the following nursing interventions and selected activities for
the nursing care plan for ineffective airway clearance: (20 pts)

INTERVENTIONS RATIONALE

1.    Encourage the client to take several

 It promotes oxygenation before controlled coughing.
deep breaths

2.    Encourage the client to take a deep  This moves air down to the bottom areas of the lungs
breath, hold for 2 seconds, and cough and opens up the air passages and moves the mucous
two or three times in succession out; coughing is also easier.

3.    Encourage use of incentive  This incentive spirometer is a hand-held breathing

spirometry, as appropriate exercise device to help the patient breathe deeply.

 Adequate fluid intake enhances dissolving of

4.    Promote systemic fluid hydration, as
pulmonary secretions and facilitates expectoration of
appropriate
mucus.

5.    Monitor rate, rhythm, depth, and

 Provides a basis for evaluating adequacy of ventilation.
effort of respirations

6.    Note chest movement, watching for

 Presence of nasal erupting and utilization of
symmetry, use of accessory muscles,
embellishment muscles of breaths may happen in light
and supraclavicular and intercostal
of incapable ventilation.
muscle retractions

 It is important to distinguish normal respiratory sounds

7.    Auscultate lung sounds after
from abnormal ones for example crackles, wheezes,
treatments to note results
and pleural rub in order to make correct diagnosis.

8.    Monitor client’s respiratory  Assists in evaluating prescribed treatments and client
secretions outcomes

 Respiratory tract infections alter the amount and

9.    Monitor client’s ability to cough character of secretions. An ineffective cough
effectively compromises airway clearance and prevents mucus
from being expelled
 10.  Monitor for increased restlessness,  These clinical manifestations would be early indicators
anxiety, and air hunger of hypoxia

2. Match the following concepts with each other. Write the letter only. Use CAPITAL letters. (2
points each)

ANSWER COLUMN A COLUMN B

A.    Upper airway obstruction, upper airway bleeding,

inability to clear lower airway secretions, laryngeal or
E 1.    Tracheostomy tracheal fracture, airway burns, need for continuous
ventilation, decreased LOC with inability to protect
airway

B.    Nasal cannula, face mask, non-rebreather, partial

B 2.    Oxygen Therapy
non-rebreather, venture mask, face tent

3.    Assessments for need to C.   Reduced oxygen in the blood characterized by a low
A
suction PO2 or Sa02

D.   Percussions over congested areas can mechanically

C 4.    Hypoxemia
dislodge tenacious secretions from the bronchial walls

E.    Surgical opening into the trachea with the creation

F 5.    Incentive Spirometry
of a stoma
 F.    Improve pulmonary ventilation, counteract the
effects of anesthesia/hypoventilation, loosen
G 6.    Tracheostomy precautions
respiratory secretions, facilitate respiratory gaseous
exchange, expand collapsed alveoli

G.   Keep duplicate tract tube with obturator at bedside,

keep foreign objects such as aerosols and powders
7.    Indications for
H away from trach, provide humidified air and 02, keep
Tracheostomy
the stomata dry, good oral and nasal hygiene, medical/
surgical asepsis

H.   Restlessness, gurgling sounds during respiration,

adventitious breath sounds when chest is auscultated,
B 8.    Chest Percussion
change in mental status, skin color, rate and pattern of
respiration, pulse rate and rhythm