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PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia Assessment Cues: Nursing diagnosis : Ineffective Airway Clearance related to presence of secretions in the tracheobronchial tree secondary to pneumonia S > Ok naman na ako, gumagaling, Pero medyo nahihirapan lang huminga > "Hindi naman ako nahihilo" O > On O2 inhalation at 7LMP via Facemask >RR of 25, shallow >tachypnea >SPo2: 87% >Has episodes of productive
Explanation of the Problem Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Objectives
Interventions
Rationale
Criteria
STO:
>Assess airway for patency.
>Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest.
>Breathing comes naturally and effortlessly to everyone. But there are some who are incapable of keeping their airways clear and their lungs healthy. Maintaining a patent airway has always been vital to life. When problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it. However, coughing may not always be easy to everyone especially to those patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular
After 5 minutes of nursing interventions patient would identify the importance of DBE and coughing exercises and perform DBE and atleast 2-3 coughing exercises
Auscultate lungs for presence of normal or adventitious breath sounds, as in the following:
Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed.
>Decreased or absent breath sounds
>These may indicate presence of a mucous plug or other major obstruction.
>Wheezing
>This may indicate partial airway obstruction or resistance.
STO: Fully met if after 8 hours of nursing interventions the client will have clear breath sounds Partially meet if there are still adventitious breath sounds but has been lessened Not met if the adventitious breath sounds are the same or worsened
>After 8 hour of nursing interventions the client will be able to maintain airway patency by having clear breath sounds
>After 5 minutes of nursing interventions the patient will verbalize understanding of 3 danger signs of pneumonia >After 5 minutes of health teaching the patient will identify 3 necessary alterations in lifestyle and daily activities to manage pneumonia >after 2days of nursing interventions the patient will have normal ranges in her oxygen saturation
>Coarse Crackles
>This may indicate presence of secretions along larger airways.
>Assess respirations. Note quality, rate pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.
>A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction.
STO: Criteria Fully met if after 5 minutes the patients identifies 3 danger signs Partially met if the patients identifies 2-3 danger signs Not met if the patient did not identify anything STO 2 Fully met if after 5
Actual Evaluation Partially met because patient still has crackles upon auscultatio n on the lung fields but has been lessened compared to the first day Fully met patient Soriano indentified 3 danger signs
Fully met patient performed DBE and 3
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia Cough >Crackles heard upon auscultation on the lung fields >expectorates whitish phlegm >No nasal flaring > no use of accessory muscles >no chest indrawing >Not cyanotic
weakness. Mechanisms that exist in the lower bronchioles and alveoli to maintain the patency of the airway include the mucociliary system, macrophages, and the lymphatics. Also, anesthesia and dehydration can alter the function of the mucociliary system. Thus, increased production of secretions in conditions such as pneumonia and bronchitis can oppress these mechanisms. >Ineffective Airway Clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased
(93% and above)
LTO: >After 3 days of nursing interventions Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
>After 3 day of nursing intervention ,the client will be able to expectorate retained secretions and maintain normal breathing measured by SPo2, RR, depth and rhythm
>Note for changes in HR, BP, and temperature.
>Note cough for efficacy and productivity
>Note presence of sputum; evaluate its quality, color, amount, odor, and consistency.
>Use pulse oximetry to monitor oxygen saturation; assess arterial blood gases (ABGs)
>Increased work of breathing can lead to tachycardia and hypertension. Retained secretions or atelectasis may be a sign of an existing infection or inflammatory process manifested by a fever or increased temperature >Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. >Unusual appearance of secretions may be a result of infection, bronchitis, chronic smoking, or other condition. A discolored sputum is a sign of infection; an odor may be present. Dehydration may be present if patient has labored breathing with thick, tenacious secretions that increase airway resistance. >Pulse oximetry is used to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Alteration in ABGS may result in increased pulmonary secretions and
minutes of health teaching the patient will perform DBE and identify 3 coughing exercises Partially met if the patient will perform DBE and identify 1-2 coughing exercises Not met if the patient does not do DBE and not identify any coughing exercise STO 3 Fully met if after 5 minutes The patient identifies 3 alterations in lifestlyle and daily activities Partially met if the patient identies 12 alterations Not met if the patient does not identify anything STO 4
coughing exercises
Not met because patient is unable to identify any of the modificatio ns due to her age constraints and weakness.
Partially
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia incidence of emphysema and a higher prevalence of chronic cough or sputum production. >There is a wide range of airway clearance interventions that nurses can choose from when they are teaching the patients and family members the strategies of secretion removal. In general, these interventions are done to maintain a patent airway, improve comfort and ease of breathing, improve pulmonary ventilation and oxygenation, and to prevent risks associated with oxygenation problems. >Pneumonia is an infection in one or both lungs. It can be caused by bacteria, viruses, or fungi.
>Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). >Educate the patient in the following: Optimal positioning (sitting position) Use of pillow or hand splints when coughing Use of abdominal muscles for more forceful cough Use of quad and huff techniques Use of incentive spirometry Importance of ambulation and frequent position changes >Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed.
respiratory fatigue. >The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing. >The proper sitting position and splinting of the abdomen promote effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Controlled coughing methods help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens atelectasis.
>Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.
Fully met if After 2 days of nursing intervention the patient will have normal range in Oxygen saturation (93% and above) Partially met if the patients oxygen saturation increases to 90% to 92% or increases from any range higher than former SPo2 Not met if the patients SPo2 decreased or remained the same LTO: Criteria: Fully met if after 3 days of nursing interventions Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to
met, patient’s oxygen saturation is now lingering at 90-91%
Partially met patient still has abnormal breath sounds (crackles), and irregular respiration but is able to cough effectively and expectorat
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia Bacterial pneumonia is the most common type in adults. >Pneumonia causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe. >Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchymathus, producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation. The airway is narrowed thus wheezes is being heard. DOB in some cases
effectively cough up secretions after treatments and deep breaths.
e secretions after treatments and deep breaths
Partially met if she has normal breath sounds, rate and depth of respirations but is not able to effectively cough up secretions after treatments and deep breath Not met if the patient does not improve at all LTO: Fully met if after 3 days of nursing interventions the patient will be able to expectorate retained secretions and maintain normal breathing measured by SPo2, RR, depth and rhythm Partially met if the
Partially met because the patient still has abnormal Spo2, and RR but is able to expectorat e secretions
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia patient is able to expectorate the phlegm but still has abnormal 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 10/16/18, from https://www.healthline.com/health/pneumonia
Nurseslabs (n.d.)Ineffective airway clearance, Retrieved on 10/16/18 from https://nurseslabs.com/ineffective-airway-clearance/
Scribd (n.d.) NCP ineffective airway clearance, Retrieved on 10/16/18, from https://www.pdfcoke.com/doc/36791581/NCP-Ineffective-Airway-Clearance
Explanation of the Problem Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Objectives
Interventions
Rationale
Criteria
STO:
>Assess airway for patency.
>Maintaining patent airway is always the first priority, especially in cases like trauma, acute neurological decompensation, or cardiac arrest.
>Breathing comes naturally and effortlessly to everyone. But there are some who are incapable of keeping their airways clear and their lungs healthy. Maintaining a patent airway has always been vital to life. When problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it. However, coughing may not always be easy to everyone especially to those patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular
After 5 minutes of nursing interventions patient would identify the importance of DBE and coughing exercises and perform DBE and atleast 2-3 coughing exercises
Auscultate lungs for presence of normal or adventitious breath sounds, as in the following:
Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate airway is obstructed.
>Decreased or absent breath sounds
>These may indicate presence of a mucous plug or other major obstruction.
>Wheezing
>This may indicate partial airway obstruction or resistance.
STO: Fully met if after 8 hours of nursing interventions the client will have clear breath sounds Partially meet if there are still adventitious breath sounds but has been lessened Not met if the adventitious breath sounds are the same or worsened
>After 8 hour of nursing interventions the client will be able to maintain airway patency by having clear breath sounds
>After 5 minutes of nursing interventions the patient will verbalize understanding of 3 danger signs of pneumonia >After 5 minutes of health teaching the patient will identify 3 necessary alterations in lifestyle and daily activities to manage pneumonia >after 2days of nursing interventions the patient will have normal ranges in her oxygen saturation
>Coarse Crackles
>This may indicate presence of secretions along larger airways.
>Assess respirations. Note quality, rate pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.
>A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction.
STO: Criteria Fully met if after 5 minutes the patients identifies 3 danger signs Partially met if the patients identifies 2-3 danger signs Not met if the patient did not identify anything STO 2 Fully met if after 5
Actual Evaluation Partially met because patient still has crackles upon auscultatio n on the lung fields but has been lessened compared to the first day Fully met patient Soriano indentified 3 danger signs
Fully met patient performed DBE and 3
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia Cough >Crackles heard upon auscultation on the lung fields >expectorates whitish phlegm >No nasal flaring > no use of accessory muscles >no chest indrawing >Not cyanotic
weakness. Mechanisms that exist in the lower bronchioles and alveoli to maintain the patency of the airway include the mucociliary system, macrophages, and the lymphatics. Also, anesthesia and dehydration can alter the function of the mucociliary system. Thus, increased production of secretions in conditions such as pneumonia and bronchitis can oppress these mechanisms. >Ineffective Airway Clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway clearance are the aged individuals who have an increased
(93% and above)
LTO: >After 3 days of nursing interventions Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
>After 3 day of nursing intervention ,the client will be able to expectorate retained secretions and maintain normal breathing measured by SPo2, RR, depth and rhythm
>Note for changes in HR, BP, and temperature.
>Note cough for efficacy and productivity
>Note presence of sputum; evaluate its quality, color, amount, odor, and consistency.
>Use pulse oximetry to monitor oxygen saturation; assess arterial blood gases (ABGs)
>Increased work of breathing can lead to tachycardia and hypertension. Retained secretions or atelectasis may be a sign of an existing infection or inflammatory process manifested by a fever or increased temperature >Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. >Unusual appearance of secretions may be a result of infection, bronchitis, chronic smoking, or other condition. A discolored sputum is a sign of infection; an odor may be present. Dehydration may be present if patient has labored breathing with thick, tenacious secretions that increase airway resistance. >Pulse oximetry is used to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. Alteration in ABGS may result in increased pulmonary secretions and
minutes of health teaching the patient will perform DBE and identify 3 coughing exercises Partially met if the patient will perform DBE and identify 1-2 coughing exercises Not met if the patient does not do DBE and not identify any coughing exercise STO 3 Fully met if after 5 minutes The patient identifies 3 alterations in lifestlyle and daily activities Partially met if the patient identies 12 alterations Not met if the patient does not identify anything STO 4
coughing exercises
Not met because patient is unable to identify any of the modificatio ns due to her age constraints and weakness.
Partially
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia incidence of emphysema and a higher prevalence of chronic cough or sputum production. >There is a wide range of airway clearance interventions that nurses can choose from when they are teaching the patients and family members the strategies of secretion removal. In general, these interventions are done to maintain a patent airway, improve comfort and ease of breathing, improve pulmonary ventilation and oxygenation, and to prevent risks associated with oxygenation problems. >Pneumonia is an infection in one or both lungs. It can be caused by bacteria, viruses, or fungi.
>Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). >Educate the patient in the following: Optimal positioning (sitting position) Use of pillow or hand splints when coughing Use of abdominal muscles for more forceful cough Use of quad and huff techniques Use of incentive spirometry Importance of ambulation and frequent position changes >Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed.
respiratory fatigue. >The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing. >The proper sitting position and splinting of the abdomen promote effective coughing by increasing abdominal pressure and upward diaphragmatic movement. Controlled coughing methods help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. Ambulation promotes lung expansion, mobilizes secretions, and lessens atelectasis.
>Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.
Fully met if After 2 days of nursing intervention the patient will have normal range in Oxygen saturation (93% and above) Partially met if the patients oxygen saturation increases to 90% to 92% or increases from any range higher than former SPo2 Not met if the patients SPo2 decreased or remained the same LTO: Criteria: Fully met if after 3 days of nursing interventions Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to
met, patient’s oxygen saturation is now lingering at 90-91%
Partially met patient still has abnormal breath sounds (crackles), and irregular respiration but is able to cough effectively and expectorat
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia Bacterial pneumonia is the most common type in adults. >Pneumonia causes inflammation in the air sacs in your lungs, which are called alveoli. The alveoli fill with fluid or pus, making it difficult to breathe. >Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchymathus, producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation. The airway is narrowed thus wheezes is being heard. DOB in some cases
effectively cough up secretions after treatments and deep breaths.
e secretions after treatments and deep breaths
Partially met if she has normal breath sounds, rate and depth of respirations but is not able to effectively cough up secretions after treatments and deep breath Not met if the patient does not improve at all LTO: Fully met if after 3 days of nursing interventions the patient will be able to expectorate retained secretions and maintain normal breathing measured by SPo2, RR, depth and rhythm Partially met if the
Partially met because the patient still has abnormal Spo2, and RR but is able to expectorat e secretions
PRIORITY 1: Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia patient is able to expectorate the phlegm but still has abnormal 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 10/16/18, from https://www.healthline.com/health/pneumonia
Nurseslabs (n.d.)Ineffective airway clearance, Retrieved on 10/16/18 from https://nurseslabs.com/ineffective-airway-clearance/
Scribd (n.d.) NCP ineffective airway clearance, Retrieved on 10/16/18, from https://www.pdfcoke.com/doc/36791581/NCP-Ineffective-Airway-Clearance
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