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.
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,...
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