Ineffective Airway Clearance
The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.
O> Patient manifested the ff:
- with unproductive cough
-with wheezes and crackles auscultated on left lower lungfield.
- presence of clear watery discharge from her nose
> Patient may manifest the ff:
Ineffective airway clearance related to presence of secretions secondary to pneumonia.
After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved.
After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.
>Establish rapport to patient and SO
>Assess patient’s condition
>Monitor and record V/S
>Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds
>Assist patient to change position every 30 minutes
>Elevate head of bed and align head in the middle
>Provide health teachings regarding effective coughing and deep breathing exercise.
>Encourage to increase fluid intake.
>Encourage steam inhalation
>Administer meds as ordered
>To gain the trust and cooperation
>To know and determine patient’s needs
>To establish base line data
>To identify areas of consolidation and determine possible bronchospasm or obstruction.
>To mobilize secretions
>To facilitate breathing
>To expel the mucous...
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