Memorial University of Newfoundland School of Nursing- Extended CER / N3512 Nursing Dx Supportive Data Intervention/Strate gies Rationale Evaluation

Ineffective airway clearance

Subjective: Patient states that her coughs are yucky Patient states she is short of breath Objective: Patient has a wet, productive cough Patients oxygen sats are between 89-94 Chest xray revealed fluid on the lungs Patients WBC count is elevated Patients breathing is shallow and laboured, as evident by respiratory assessment Patient using accessory muscles to breathe deeply Dyspnea Increased respiratory rate (>30)

Auscultate breath sounds before and after each Ventolin treatment (Q3H).

Goal(s)/Expected Outcome(s) Patient will demonstrate clear breath sounds and unlaboured breathing by the end of the clinical week. O2 sats will be maintained above 92% without supplemental oxygen by the end of the clinical week.

Monitor respiratory pattern, including: rate, depth, and patients effort.

Breath sounds are normally clear. The presence of crackles during breathing indicates fluid in the airway, and wheezing can indicate obstruction. M. Doenges, MF Moorhouse, & A. Murr. Nurses Pocket Guide. (2006). Normal respiratory rate for a pediatric patient is 20-25. When secretions are present and breathing is laboured, respiratory rate will increase. Oxygen saturation less than 90% indicates oxygenation problems. Clark, AP, Giuliano K., Chen HM: Pulse oximetry revised. Clin Nurse Spec 20(6), 268-272, 2006.

Goals not met. Patient has equal, bilateral breath sounds which are clear and unlaboured in the upper lung lobes. Patient does not have air movement in the lower lobes. Infection/inflammati on does not seem to be clearing with regular corticosteroids, and antibiotic treatment. Repeat chest xray has been ordered. O2 sats are not being maintained above 92%. Patient still requires blowby oxygen supplementation.

Monitor pulse oxygen saturation at regular intervals (Q1H).

Administer oxygen and ventolin as ordered.

Patient is breathing shallow Patient has nasal flaring

Monitor for side effects of bronchodilator and steroid,

Oxygen can increase the patients O2 sats and ventolin will open up airways and reduce inflammation. P. Swearingen. Manual of medical surgical nursing care. (2008). Bronchodilators and steroids can cause tachycardia, anxiety, tremors, insomnia. A. Perry & P. Potter. Clinical Nursing Skills & Techniques. (2010).