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.