Ineffective Airway Care Plan.
Introduction
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,
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,
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