For this case study I have chosen three problems which are (i) airway clearance, ineffective (ii) breathing pattern, ineffective (iii) and pain. (i) Airway clearance, ineffective.
intervention| rationale| evaluation|
Vital signs monitored and recorded every 15 min for 1 hour and then every half hourly.| This is for baseline comparison.| If there is a major difference between the baseline and the other assessments then the nurse would be able to pick it up and act according to it.| Assess level of consciousness and ability to protect airway| Agitation, irritation, confusion and restlessness which might lead to hypoxemia. (Brian 2011)| Participates and understand instructions. E.g. deep breathing exercises. | Positioning, semi fowlers or upright| Proper positioning helps to drain secretions with the help of gravity | Able to cough and breathe more freely.| Encourage expulsion of sputum; suction when needed| Thick, secretions are a major reason for impaired gas exchange in the alveoli. Proper suctioning may be required when cough is ineffective for removal of secretions.| After suctioning patient’s airway will be free of sputum and secretions| Encourage deep breathing from diaphragm and coughing.| This will promote lung expansion. Increased airflow. (Maury 2011)| Moist air enters the airway. | Monitor O2 saturation throughout acute phase.Establish a chest x-ray.| Establishes baseline in order to monitor oxygen exchange regression or progression. | If the oxygen is fluctuating below the required amount it can be reported immediately and therefore actions can be taken.| Increase fluid intake. Up to 300ml per day. | Hydration helps reduce the thickness of secretions. | Sputum excretion will be easier for the patient which therefore clears up the airway. | Administer O2 at no more than 2L per min| COPD patients retain O2 (fremault 2008)| Saturation in an adequate level.|
(ii) Breathing pattern,...