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Actual NCP #1: Ineffective airway clearance r/t impaired neuromuscular function

Assessment Explanation of the


problem
Objectives Nursing Interventions Rationale Evaluation
S> Mukhang nahihirapan
huminga mama ko, kagabi
pa yan, as verbalized by
the daughter.

O>Shallow breathing with
respiratory rate of 28 cpm
>Fatigue as evidenced by
weak in appearance
>Alterations of depth when
breathing
>Dyspnea noted
>Use of accessory muscles
when breathing
>Crackles heard upon
auscultation
>Positive sputum secretions



Nursing Diagnosis:
A>Ineffective airway
clearance r/t impaired
neuromuscular function
The development of
atherosclerosis leads to
the development of
atherothromboembolic
material disrupting the
circulation process of the
blood. The obstruction on
the blood vessels affects
the brain tissues and their
function (brain damage).
In our patient, right brain
stem is affected where
there is an alteration of
the gag reflex and that the
patient has inability to
expectorate phlegm
leading to ineffective
airway clearance.





STO:
After 2 hours of
rendering effective
nursing interventions,
the client will be able to
mobilize secretions by
demonstrating the
following:

A. Proper deep
breathing exercises
B. Coughing
exercises
C. Positioning the
client in semi
fowlers/ high
fowlers position
as tolerated



Dx:

Assessed airway
for patency

Monitored
respirations and
breath sounds,
noting rate and
adventitious
sounds present

Assessed
presence or
degree of
dyspnea.
Determined
precipitating
factors
Tx:



To identify
adequacy of
airways

These may signify
presence of
accumulated
secretions, or other
major airway
obstruction
To ascertain
degree of dyspnea
and to consider
probable causes.


For optimal lung
expansion and
better air exchange
STO: GOAL MET
After 2 hours of rendering
effective nursing interventions,
the client is able to
demonstrate the following:

A. Proper deep breathing
exercises
B. Coughing exercises
C. Positioning the client in
semi fowlers/ high fowlers
position as tolerated


LTO: GOAL MET
After 24 hours of rendering
effective nursing interventions
the client has maintained
patent airway as evidenced by:

A. Normal breath sounds
LTO:
After 24 hours of
rendering effective
nursing interventions
the client will maintain
patent airways as
evidenced by:
A. Normal breath
sounds
B. Normal rate and
depth of respirations
C. Absence of
dyspnea

Positioned in
semi fowlers
or high
fowlers
Promoted bed
rest and
offered care
needed
during acute
or prolonged
exacerbation.

Elevated
head of bed
and assisted
in frequent
position
change



Edx:

Instructed to
Necessary
cessation of activity
is important to
prevent more
serious respiratory
compromise

To take advantage
of gravity
decreasing
pressure on the
diaphragm and
enhancing
ventilation and
drainage of
different lung
segment


Systemic hydration
keeps secretions
moist and easier to
expectorate.

B. Normal rate and depth
of respirations
C. Absence of dyspnea



adequately
hydrate
through
increasing
fluid intake

Demonstrated
and educated
on
diaphragmatic
breathing and
effective
coughing
techniques.




Instructed to
avoid
bronchial
irritants such
as cigarette
smoke,

Patient will
comprehend the
underlying principle
and proper
techniques which
help improve
ventilation and
mobilize secretions
without causing
breathlessness and
fatigue
Bronchial irritants
cause broncho-
constriction and
increased mucus
production, which
then interfere with
airway clearance.
Smoking adds to
bronchospasms
and enlarging
mucus production
in the airways.
aerosols and
extremes of
temperature
and fumes
Emphasized
and explained
the effects of
smoking, as
well as
second hand
smoke.