PLANNING/IMPLEMENTATION/EVALUATION (See Grading Rubric for NCP Criteria)

Nursing Diagnosis Ineffective Airway Clearance r/t trachea-bronchial infection, retained secretions AEB nonproductive cough, change in respiratory rate with secretions Long Term Goal Pt. will maintain patent airway

Outcome Criteria
One outcome criteria for each intervention. Number each one.

Interventions
Label each intervention as: Assess/Monitor/Independent Dependent/Teaching/Collaboration

Rationale
Answers why, how, what your interventions will help solve, prevent or lessen the stated problem specific to this patient.

Evaluation
Evaluate the patient outcome NOT the intervention M: This patient maintained a respiratory rate of 12-20. Ongoing

1) Pt. will have respirations of 12-20 as assessed q4hrs

Monitor respiratory rate, rhythm and depth q4hrs

Monitoring the respiratory rate will allow the nurse to determine if the patient is having sufficient oxygen intake. Due to this patient having pneumonia and respiratory complications the respiratory rate will increase. A change in respiratory rate may show an exacerbation in the infection. Respirations below 12 and over 12-24 may indicate a need for immediate intervention. Monitoring provides a means for comparison with baseline. (NDH 129) An increase in temperature indicates infection. This pt. has pneumonia which is an infection in the lungs. If a temp, spikes while on the antibiotic, it may indicate the infection is getting worse or going septic. This patient is also at a risk for aspiration, fever can be related to infection in the lung due to aspiration. This can affect proper mobilization of secretions for the patient. (NCP 130, Nursing 102 Lecture notes Respiratory Rationales) Auscultation assesses the movement of air through the tracheal bronchial tree and detects mucous or obstructed airways. Abnormal sounds result from air passing through moisture, mucus or narrowed airways. Adventitious lung sounds are extra breath sounds that are abnormal including crackles, rhonchi, wheezes and pleural rubs. Crackles would

2) Pt will maintain temp of 9799 as measured q4hr

Assess temperature q4hr and prn

M: This patient maintained a temp of 97-99. Resolved

3) Pt. will have clear lung sounds in two days.

Assess lung sounds q4hrs

P: This patients lung sounds were rhonchi bilaterally. This patients lung sounds were cleared with an effective cough within 2 days

indicate fluid in the lung tissue, diminished lung sounds over an obstruction, rhonchi indicate air moving through secretions, these would indicate ineffective airway clearance. (Lewis page 507-512) 4) Patient will have moist mucous membranes and pink skin as observed q4hrs Assess skin color and mucous membranes q shift and prn Pale or cyanotic color indicates an increased concentration of deoxygenated blood and indicates that breathing is no longer effective to maintain adequate oxygenation of tissues. Central cyanosis of the tongue and oral mucosa is an indicator of severe hypoxia that can be related to respiratory distress caused by retained secretions in the airway. (NCP page 31, NDH page 403) O2 therapy is frequently used in the treatment of pneumonia and COPD and other problems associated with hypoxemia. Long term therapy improves survival, cognitive performance and sleep. The goal of O2 therapy is the supply the patient with adequate O2 carrying ability to the blood and deliver O2 at concentrations than ambient air. This patient has pneumonia, which includes secretions in the alveoli, which make it difficult to move air through the alveoli. (Lewis 618) An upright position allows for maximal lung expansion and chest expansion. While lying flat causes abdominal organs to shift towards the chest, which crowds the lungs and makes it difficult to breathe. A HOB up 90 degrees optimizes respirations and creates a decreased incident of pneumonia related to aspiration. Maintaining high fowlers with and after meals can help decrease aspiration pneumonia. NDH 129,151

Ongoing

M: This patients skin color was pink, and moist mm. Ongoing

5) Patient will maintain 02 sat 95-100% as assessed q4hrs

Administer oxygen as 2L n/c as ordered by MD q day and prn Dependent

M: This patient maintained 02 sat 95-100% Resolved

6) Patient will exhibit no signs of aspiration at all times

Elevate HOB at 90 degrees at all times Independent

P: This patient exhibited no signs of aspiration, but the patient did have issues clearing secretions even in high fowlers. Resolved

7) Patient will have

productive cough within 2 days

Assess for presence of cough and characteristics of sputum q4hrs and prn Independent

A cough is an abnormal finding. It is important to assess this to monitor for change in frequency of cough and whether the cough has become more productive. Note the sound of the cough, frequency and time span associated with the cough. It is also important to assess the sputum for color, frequency, consistency and odor. Normal sputum is clear or gray and minimal, abnormal sputum is green, yellow, or bloody and may be copious. These assessments are important for the patient with pneumonia to monitor for a diversion from the baseline and progression. (NDH 130) Oropharyngeal blind suctioning (suctioning without a tracheal tube in place) is done if the patient is unable to expectorate secretions. The need for suctioning is indicated with coarse crackles, rhonchi over large airways, moist cough, increase in RR, SOB, restlessness and the presence of excessive secretions. The use of suctioning can assist in mobilizing secretions and creating a patent airway for the patient. This patient had SOB r/t retained secretions and the need for suctioning created a patent airway. (Lewis 1753, 530) Thick and viscous secretions are hard to expel. Adequate fluid intake (2-3L/day) keeps secretions thin and easier to move. Water is the most physiological compatible expectorant. Encouraging fluids liquefy the secretions, which will improve expectoration of secretions, prevent mucous plugs, which can cause hypoxia or atelectesis. Increased fluids will prevent bacterial growth of microorganisms as a stasis of secretions that could become a medium for bacterial growth, such as pneumonia. (Lewis 1753, Nursing 102 Lecture Notes, Respiratory Rationales)

U: This patient was having difficulties expelling sputum and had a nonproductive cough without the use of suctioning. Ongoing

8) Patient will effectively self suction retained secretions as needed

Encourage self suctioning as needed and q2hrs Independent

P: When the patient suctioned, secretions were cleared but had to suction continuously and had difficulty getting all secretions. Ongoing

9) Patient will consume 20003000ml/24hrs

Encourage adequate PO fluid intake q shift Independent

M: This patient consumed 20003000ml/day of fluids Resolved

10) Patient will have mobilization of secretions by day 2

Reposition patient q2hrs while in bed Independent

Turning and positioning the patient every 2 hours promotes loosening and mobilization of secretions, circulation and prevents thoracic compression and inhibition of air through the lungs. This allows for better aeration and gas exchange of O2 and CO2. Some positions the patient may be repositioned are side lying from left to right side, increasing the HOB to prevent aspiration pneumonia and positioning from side lying to back every 2 hours. It is very important for to be turned every 2 hours because they are paraplegic and do not have the ability to reposition themselves on their own and be ambulatory. It is crucial to reposition for the mobilization of secretions and airway clearance for this patient. ( Nursing 102 Lecture Notes, Respiratory Rationales) If secretions are obstructing the airway, encourage the patient to cough. The patient with a neuromuscular weakness (paraplegia) may not be able to generate sufficient pressures to produce an effective cough. Augmented cough may be beneficial to these patients. Perform by placing the palm of your hands on the patients abdomen below the xiphoid process and as the patients ends a deep inspiration and begins expiration, move your hands forcefully downward, increasing abdominal pressure and facilitating a cough. Another effective cough technique is the huff cough, which prevents the glottis from closing during the cough. These techniques may increase expiratory flow and facilitate secretion clearance. (Lewis page 1752-1753) Incentive spirometer facilitates adequate clearance of secretions and prevents atelectasis. IS encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. IS also promotes deep breathing and prevents or treats atelectasis. It is important for this patient to use the IS because they are bed/chair ridden and also have respiratory complications of COPD and pneumonia. (P+P page 848)

P: This patient was t&p 2hrs, and the mobilization of secretions became more effective than they were on day of admission Resolved

11) Patient will cough deeply 2 times q2hr

Teach patient effective cough methods q day Independent

M: This patient used the augmented cough and expelled secretions and then suctioned. Ongoing

12) Patient will demonstrate use of IS 10x/hr

Encourage patient to use incentive spirometer q hour and prn Independent

P: This cannot be evaluated because the IS was introduced to patient on 10/4. Patient was encouraged to use this 10x/hour. The patient demonstrated understanding by showing how to use IS. Ongoing

Outcome Criteria
13) Pt. will demonstrate use of Acapella qhr

Interventions
Encourage use of Acapella q hour while awake and prn Independent

Rationale
An Acapella is a hand held device that uses pulmonary expiratory pressure and airway vibrations to mobilize airway secretions. The patient may also inhale through it and nebulizer can be attached to the Acapella. This device is important for this patient because the patient has neuromuscular weakness and may be difficult for the patient to expectorate secretions on their own. (Lewis page 624)

Evaluation
M: This patient demonstrated use of the Acapella every hour and assisted in the mobilization of secretions for the patient. Ongoing

14) Pt. will show decreased signs of infection (decreased temp, decreased chest pain, improved breathing) by day 2

Administer Vancomycin 1000mg IVPB q12hrs per MD order Dependent

Vancomycin (Vancocin) is used as a bactericidal against susceptible death, treatment of potentially life threatening infections when less toxic antiinfectives are contraindicated such as pneumonia. Prompt treatment with the appropriate antibiotic almost always cures bacterial causes of pneumonia. Indications of improvement with Vancomycin include decreased temperature, improved breathing, reduced chest pain and decreased in trachea-bronchial secretions. (Lewis 549, Davis Drug Book ebook)

M: This patient exhibited decreased signs of infection Resolved

15) Pt. will show no signs of aspiration daily

Provide mouth care to patient b.i.d and prn

Providing meticulous mouth care consists of brushing teeth at least two times a day. Good oral care can prevent contaminations of the mouth and prevent food and oral secretions to be aspirated. Dental care has been shown to be effective in preventing aspiration and hospital acquired pneumonia. (NDH 153).

M: This patient showed no signs of excessive secretions or food around mouth. The pt. exhibited no signs of aspiration while hospitalized.