Ineffective Airway

ASSESSMENT Subjective: “Naglisod siya pagghinhawa.”

as verbalized by the client’s wife. Objective: On endotracheal tube attached to a mechanical ventilator Abnormal breath sounds: wet crackles on (R) and (L) lung bases. Dyspnea; use of accessory muscles for respiration: elevated shoulders. Increase in respiratory rate: RR-25 cpm Secretion characteristics: yellowish in color and 40 ml in amount collected in an 8-hr shift. Chest x-ray reports haziness on both lower hemithorax taken on September 7, 2006. Restless

DIAGNOSIS Ineffective airway clearance related to increased production of bronchial secretions secondary to fluid shift to extravascular compartment.

PLANNING During the client’s stay at the hospital he will be able to maintain patent airway as evidenced by: >Independence from oxygen and ventilatory support >Normal respiration as evidenced by absence of dyspnea and adventitious breath sounds (wet crackles). >Normal breathing pattern: RR = 12-20 cpm >Absence of bronchial secretions >Sustain respiratory rate within normal range: RR-12-20 cpm. >Display decreasing amount of secretions (less than 40cc).

INTERVENTION

RATIONALE

Assessed respiratory rate.

Provides a basis for evaluating adequacy of ventilation. Use of accessory muscles of respiration may occur in response to ineffective ventilation.

Noted chest movement; use of accessory muscles during respiration. Auscultated breath sounds; noted areas with presence of adventitious sounds.

Crackles indicate accumulation of secretions and inability to clear airways. Expectorations may be different when secretions are very thick.

Documented respiratory secretions: character and amount of sputum. Maintained patient on moderate high back rest.

Positioning helps maximize lung expansion. To maintain adequate airway patency.

Checked for obstructions: accumulation of secretions. Suctioned patient limited to 5-sec duration.

Duration should be limited to reduce hazard of hypoxia, damage airway mucosa and impair cilia action. Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.

EVALUATION At the end of the shift, the client was able to display patency of airway as manifested by: . Client’s respiratory rate is within normal range: RR18 bpm. Secretions decreased in amount from 40 cc to 30 cc collected in an 8-hr shift (Continue assessment of respiratory status and suctioning as needed). Client’s restlessness was alleviated and remained calm.