ASSESSME DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATION

NT IS
Objective Ineffective After 8 Independent: Effectiveness
- pale in airway hours of • Assess airway for >Maintaining the - Was the
appearance clearance nursing patency. airway is always the patient able to
- dyspnea related to intervention first priority, maintain
- uses ineffective s, the especially in cases of patent airway?
accessory cough patient's trauma, acute -Was the
muscles secretions neurological patient able to
when will be decompensation, or mobilize her
breathing mobilized • Auscultate lungs for cardiac arrest. secretions?
- productive and airway presence of normal -Was the
cough will show or adventitious patient able to
- RR=41 decreased breath sounds, as in have patent
cycles per in the following: airway?
minute secretions o Decreased or
absent breath Adequacy
>These may indicate
sounds -Was all the
presence of mucus
planned
plug or other major
nursing
airway obstruction.
o Wheezing interventions
>These may indicate
are enough in
increasing airway
achieving and
resistance.
o Coarse sounds maintaining
>These may indicate
patent airway?
presence of fluid
-Was all the
along larger airways.
resources of
• Assess respirations; the nurse like
>Abnormality time and effort
note quality, rate, indicates respiratory
pattern, depth, are enough?
compromise.
flaring of nostrils,
dyspnea on Appropriaten
ess
exertion, evidence
of splinting, use of -Was the
interventions
accessory muscles,
and position for mentioned are
applicable and
breathing.
beneficial to
>Increasing the patient?
• Assess changes in
mental status. lethargy, confusion,
restlessness, and/or
irritability can be
early signs of Acceptability
cerebral hypoxia. - Was the
family willfully
• Assess cough for accepted the
effectiveness and >Consider possible
causes for interventions
productivity. done to the
ineffective cough
(e.g., respiratory patient.
muscle fatigue,
severe
• Note presence of bronchospasm, or
sputum; assess thick tenacious
quality, color, secretions).
amount, odor, and
consistency. >This may be a
result of infection,
bronchitis, chronic
smoking, or other
condition. A sign of
infection is
 discolored sputum
• Assist patient in (no longer clear or
performing white); an odor may
coughing and be present.
breathing
maneuvers. >These improve
• Instruct patient in productivity of the
the following: cough.
o Optimal
positioning
(sitting position) >Directed coughing
o Use of pillow or techniques help
hand splints mobilize secretions
when coughing from smaller airways
o Use of to larger airways
abdominal because the
muscles for coughing is done at
more forceful varying times. The
cough sitting position and
o Use of quad and splinting the
huff techniques abdomen promote
o Use of incentive more effective
spirometry coughing by
o Importance of increasing
ambulation and abdominal pressure
frequent and upward
position diaphragmatic
changes movement.

• Use positioning (if

tolerated, head of
bed at 45 degrees;
sitting in chair,
ambulation).
>These promote
• Encourage oral better lung
intake of fluids expansion and
within the limits of improved air
cardiac reserve. exchange.

>Increased fluid
intake reduces the
viscosity of mucus
• Demonstrate and produced by the
teach coughing, goblet cells in the
deep breathing, and airways. It is easier
splinting for the patient to
techniques. mobilize thinner
secretions with
coughing.
Dependent:
• Administer >Patient will
medications: understand the
o Mucolytics (e.g. rationale and
Guaifenesin) appropriate
techniques to keep
the airway clear of
secretions.
 >Relieves
respiratory
o Bronchodilators difficulties by
(e.g. Albuterol) hydrolyzing
glycosaminoglycans,
tending to break
Collaborative: down/lower the
• Consult respiratory viscosity of mucin-
therapist for chest containing body
physiotherapy and secretions/compone
nebulizer nts, thereby
treatments as dissolving thick
indicated (hospital mucus.
and home >Reduces resistance
care/rehabilitation in the respiratory
environments). airway and increases
airflow to the lungs.

>Chest
physiotherapy
includes the
techniques of
postural drainage
and chest percussion
to mobilize
secretions in smaller
airways that cannot
be removed by
coughing or
suctioning.