Nursing Diagnosis: Ineffective airway clearance may be related to excessive secretions and ineffective coughing.

possibly evidenced by: a. statement of difficulty of breathing with persistent cough with whitish sputum production. b. abnormal breath sounds such as wheezing upon exhalation. Goals of care Within 16 hours of nursing and medical intervention, the patient will be able to: a. Improve airway clearance by coughing effectively and expectorating secretions. b. Maintain patency of airway status with clear breath sounds. Nursing Interventions INDEPENDENT Assessment: a. Auscultate breath sounds. Note Adventitious breath sounds such as wheezing, crackles and ronchi. b. Assess respiratory rate, depth, noting the use of accesspry muscles, and inability to speak or converse. Rationale Evaluation Patients Response

Some degree of bronchospasm is present with obstructions in airway and may be manifested in adventitious breath sounds. Useful in evaluating the degree of respiratory distress and chronicity of the disease process.

DONE

Patient produces a wheezing sound when exhaling upon auscultation.

DONE Client manifested respirations with a respiratory rate of 23 breaths per minute with minimal use of accessory muscles and is slightly labored. DONE Patient manifests bilateral fremitus with vibrations best heard apex of the lungs. Client verbalized that his cough is accompanied by whitish secretions and is slimy.

c. Palpate for fremitus.

Decreased vibratory tremors suggest fluid collection or air trapping. Cough can be persistent but ineffective, especially if client is elderly, acutely ill, or debilitated.

DONE

d. Observe characteristics of cough. Therapeutic:

DONE

e. Assist client to assume position of comfort by elevating the head of the bed , having client lean on overbed table or sit on the edge of the bed. f. Keep environmental pollution to a minimum by sweeping dust and dirt scattered on the floor of the room of the patient. Health teachings: g. Teach client to maintain adequate hydration by drinking at least 8-10 glasses of fluid per day with a minimum fluid intake of about 3000ml/day. h. Encourage and recommend that client should drink warm fluids . COLLABORATIVE Assessment: a. Monitor lung sounds every 4 to 8 hours and before and after

Elevation of the head of the bed facilitates respiratory function by use of gravity and eases difficulty of breathing.

Client claims that he breathes well and is comfortable with his position. DONE

Precipitators of allergic type of respiratory reactions might trigger or exacerbate onset of acute episode. DONE

Patient verbalized that he feels calm and safe with a clean environment and can breath well.

Hydration helps decrease the viscosity of secretions, facilitating expectorations. DONE

Patient claims that he feels relieve from coughing after drinking plenty of fluids.

Using warm fluids may decrease bronchospasm. DONE

Client verbalized that drinking warm fluids makes him feel relieved from difficulty of breathing .

Adventitious breath sounds present in the large airways may impair airway patency. Thick secretions lining the

DONE Client manifested wheezing after exhalation and verbalized that he exerts

coughing episodes. b. Assess the condition of the oral mucous membranes. Therapeutic: c. Offer oral care every 2 hours. d. Perform chest physical therapy, if needed and instruct client and significant others the purpose of this technique. e. Administer cough suppressants. Health Teachings: f. Teach and supervise effective coughing techniques. g. Teach client incentive spirometry.

mouth when client coughs impairs the airway passages. Helps removes thickened secretions along the linings of the mouth. Chest physical therapy techniques use forces of gravity and motion to facilitate secretion removal.

DONE BY PATIENT

force in every breath. Patient verbalizes that he can breath well without the presence of thickened secretions in his mouth. Client claims that he can eat and breath better without the secretions in his mouth.

DONE

DONE BY STAFF NURSE Patient verbalized that he feels relieved after the therapy and feels comfortable breathing and coughed out secretions with whitish sputum.

DONE Persistent, exhausting cough may need to be suppressed to conserve energy and permit client to rest. DONE Proper coughing techniques conserve energy, reduce airway collapse and lessens client frustrations. Is an objective measure of the depth of inhalation to promote lung expansion.

Patient verbalized that he feels relaxed and can rest adequately after taking the medication. Client claimed that after performing coughing techniques he feels that he can breath spontaneously without minimal effort. Patient claims that he now knows the purpose of incentive spirometry and how

to perform using it. General Evaluation: Within 7 hours of nursing intervention, patient was able to Improve airway clearance by coughing effectively and expectorating secretions and maintain patency of airway status with clear breath sounds, goals were completely met.