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ProblemSubmitted by Nedy Lynne R. #1: Center Ineffective cough Due to the patients BSN IV-D1 inability to cough effectively, as well as S> Medyo 2012 the increased nahihirapan akong huminga production of thick kasi yung plema mucus in the tracheobronchial ko, hindi ko tree, the patient is mailabas. not able to expectorate or clear O> crackles the secretions or noted upon obstructions at the auscultation on respiratory tracts. Thus, maintaining a both lung fields clear airway is not > Ineffective achieved. cough with thick Due to these sputum production noted conditions, the patient has a difficulty in > use of vocalizing, agitated, accessory restless, and uses her respiratory accessory muscles muscles observed such as the sternocleidomastoid > Altered depth muscle to breath. The of breathing rate and depth of breathing is also > Dyspnea altered. > Difficulty vocalizing Reference: > Agitated http://www.caneclick > Restlessness noted Nursing Diagnosis: Ineffective airway clearance related to retained secretions in the tracheobronchial
Ginez
Objectives of Care
Nursing Interventions
Scientific Rationale
Evaluation
STO Within 1 hour of effective nursing care and intervention, the patient will: 1. Verbalize understanding on the appropriate treatment regimen to correct present condition such as: a.) assisting the patient in nebulization. b.) maintaining a semi-fowlers position. c.) mobilization of secretions through effective coughing and DBE. 2. Participate in management regimen, within the level of capability to reduce agitation and restlessness due to current condition. LTO After 8 hours of effective nursing care and intervention, the patient will:
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Doenges, Marilyn E., Moorhouse, Mary Frances, Murr, Alice C. Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales. 11th edition
Ilocos Training and Regional Medical Dx Noting the location of the 1. Auscultate lungs noting STO sounds helps indicate January 17,MET if: areas with normal or GOAL where the airway adventitious breath sounds. After an hour of obstruction is. Crackles nursing care and may indicate presence of intervention, the mucus plug. client was able to: 1. Verbalized 2. Note cough for efficacy Cough is a vital mechanism understanding on and productivity. to clear the airways the appropriate especially with presence or treatment regimen stasis of secretions. to correct present condition. Determining the 3. Note for sputum 2. Fully participated in characteristics of sputum production and viscosity. management regimen, and monitoring its changes within the level of are significant and useful in capability. devising a plan. 4. Note rate and depth of GOAL PARTIALLY Any abnormality signifies respirations, dyspnea on MET if: respiratory compromise. exertion, and use of After an hour of accessory muscles. nursing care and intervention, the 5. Assess for presence of client was able to: discomfort that affects Any discomfort can result 1. Participated in the respirations and ability to to shallow breathing and management regimen, cough such as agitation and ineffective cough. within the level of restlessness. capability but expressed doubt on the effectiveness of Tx the said treatment 1. Assist and support regimen. patient in performing Breathing and coughing coughing and breathing GOAL NOT MET if: exercises improve exercises, if indicated. After an hour of efficiency of respiration 2. Elevate head of bed, as nursing care and and cough. needed. Enhances optimal chest intervention, the expansion, making it easier client was not to breathe and improving participative to physiological or nursing care and 3. Adjust patients position psychological comfort. interventions. to facilitate mobilization of LTO retained secretions. Position changes promote GOAL MET if: mobilization of secretions After 8 hours of for easier removal through nursing care and coughing and improving intervention, the
Assessment
Submitted by Nedy Lynne R. Ginez Center Problem #2: Risk Aspiration can occur STO when the protective BSN for Aspiration IV-D1 Within 30 airway reflexes are minutes of 2012
O> airway reflexes are decreased due to productive cough\
decreased. Due to the inability to cough and expectorate/ clear the secretions effectively, the patient is at risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into tracheophayngeal passages.
Objectives of Care
Nursing Interventions Dx 1. Assess cough and gag reflexes. 2. Observe swallowing ability: a.)Assess for coughing or ability to clear throat after swallowing.
b.)Check for residual food in mouth after eating. c.)Monitor for regurgitation of food or fluid through nares. d.)Assess for choking during and after drinking or eating.
Scientific Rationale
Evaluation
>cough with
thick secretions noted >unable to expectorate secretions effectively > ineffective swallowing and gag reflex noted
Reference:
Nursing Diagnosis: Risk for aspiration related to copious and thick secretions as manifested by productive cough, inability to expectorate secretions
effective nursing care and intervention, the patient will: 1. Verbalize understanding on the causative/ risk factors of aspiration. 2. Participate in appropriate nursing interventions to prevent aspiration such as a.) observing proper chewing and swallowing of food b.) facilitating clearing of airways through effective coughing c.) elevation of bed and proper positioning to facilitate drainage of secretions.
Tx 1. Assist in selecting food according to swallowing ability. Offer foods with consistency that patient can swallow, giving semisolid foods and avoiding pureed and mucus-producing foods (milk). Feed in small amounts. Cut foods into small pieces. Offer foods or liquids that can be formed into a bolus before swallowing.
2. Maintain upright or high fowlers position.
Too large pieces of food may lodge on the patients throat and cause aspiration. There is greater control in swallowing liquids of thick consistency, and lesser chances for reflux.
LTO After 8 hours of effective nursing care and intervention, the patient will:
The upright position assists the gravitational flow of food or fluid as it passes the alimentary tract.