Julia Batchelor

Nursing Care Plan

03/15/2014

Nursing Diagnosis: Ineffective Airway Clearance r/t secretions aeb adventitious breath sounds. Goal: Client will demonstrate improved airway clearance before discharge. Intervention 1. Assess Lung Sounds qshift Scientific Rationale 1. Patients with a respiratory condition must receive a focused respiratory assessment frequently to ensure adequate resp. status. Adventitious lung sounds can indicate fluid, inflammation, infection, or diminished air flow. Listening to lung sounds helps hcp to determine respiratory status of the patient. 2. A patient with a respiratory infection may have trouble maintaining adequate oxygen in the blood. Spo2 is an effective, non-invasive way to monitor how much oxygen is in the peripheral circulation. If pulse o2 become too low it may be difficult for a patient to recover adequate oxygenation. Therefore continuous or frequent Outcomes 1. Client will demonstrate clear lung sounds before discharge. Evaluation of Outcomes 1. Unmet. Client demonstrates rhonchi throughout lung fields. Ongoing.

Independant

2. Monitor Spo2 q4h and prn sob.

2. Client will maintain Spo2 > 95% continuously.

2. Partially met. Client demonstrates Spo2 95% consistently. Ongoing.

Independant

3. Assess Respiratory Rate, Pattern, and Effort q4h.

Independent

4. Administer Albuterol Sulfate aerosol neb. Q2h prn wheezing.

Dependant/Collaborative

monitoring is necessary. 3. A patient with ineffective airway clearance must receive frequent, focused respiratory assessments. Early signs of distress (retractions, accessory muscle use, nasal flaring, expiratory grunt, cough) must be identified promptly so interventions can be made. Patients can change status quickly so it is even more important to assess frequently. 4. Albuterol is a bronchodilator used to open airways that may be inflammed. It can reverse inflammation for patients with respiratory disorders. Regular treatment with a bronchodilator can decrease the work of breathing for this patient. 5. Ceftrioxone may be used for a patient with a bacterial infection. A patient with ineffective airway clearance, diminished respiratory status, and exposure to

3. Client will demonstrate RR <22 with regular rhythm and depth continuously without distress.

3. Met. Client demonstrates RR 22 with regular rhythm and unlabored breathing. Ongoing.

4. Client will demonstrate clear improved sounds after treatments.

4. Partially met. Client continues to demonstrate adventitious lung sounds. Rhonchi is diminished for short period following treatments. Ongoing.

4. Administer Ceftrioxone Sodium 1,000mg in NaCL 50 mls @ 100ml/h IV q12H dependant

5. Client will demostrate improvement of bacterial infection before discharge.

5. Partially Met. Client has CBC that indicates absence of bacterial infection. Ongoing.

5. Assess activity tolerance qshift

independant

hospital germs could be considered at high risk for infection. The patient could also have an unidentified bacterial infection contributing to respiratory problems. Therefore, treatment with a bactericidal can help prevent further problems in this client. 6. Patients with ineffective airway clearance may display shortness of breath and activity intolerance. Assessment of activity intolerance d/t sob can help determine respiratory status and planning for these patients. If a patient has SOBE care can be clustered and paced to reduce activity intolerance.

6. Client will be alert and able to complete ADLs with assistance during daytime hours.

6. Met. Client demonstrates ability to tolerate ADLs when paced. Ongoing.

6. Assess Vital Signs q4h independant

7. Assessment of vs is an effective way of determining patients status. VS q4h is often enough to identify a change in time for intervention, while still

7. Client will maintain her baseline VS of Temp (97.9100.4 ), Pulse (60-100), R(12-22), BP (160/70110/55) each shift.

7. Met. Client has maintained vs within designated parameters during each q4h assessment. Ongoing

Met. Ongoing.

8. Refer to Respiratory upon admittance

9. Teach turn, cough, deep breath q shift.

Resources:

allowing rest time for the patient. An increase in temperature may indicate infection. 8. This patient has a respiratory condition and needs focused assessment and treatment by specialized staff. Respiratory staff can administer treatment and assess patient frequently. This provides a higher level of care for the patient. 9. Secretions causing ineffective airway clearance need to be removed to improve respiratory status. Repositioning and coughing can loosen secretions. Deep breathing can ensure alveoli are filled and help prevent collapse. Patients should be reminded and demonstrate learning of TCDB often. Nursing Diagnosis Text, Ackley and Ladwig pages 402-409 Patients with frequent

8. Client will receive assessment and treatments from respiratory staff q2h and prn.

8. Met. Client has been assessed and treated by respiratory staff q2h and prn. Ongoing.

Met. Ongoing.

Client will demonstrate TCDB each shift.

Met. Patient continues to reposition, cough, and breath to loosen and expel secretions. Ongoing.

Met. Ongoing.

Daviss Drug Guide, 13th Edition

Met. Ongoing.

10. Position in semi-

Client will remain in semi-

Client is repositioned in a

Met. Ongoing.

fowlers position when resting. independant

11. Provide small, frequent feedings q4h. independant

12. Schedule rest periods before and after activity.

13. Teach providers identification of exacerbating respiratory

cough and respiratory difficulty may need to be placed in an upright or semi-fowlers position to aid breathing. This position makes it easier for the patient to breath. It can also prevent aspiration of mucous or stomach contents when patient coughs or vomits d/t cough. A patient with labored breathing often demonstrates reduced appetite and/or fatigue. The work of breathing can make eating a challenge. Offering small frequent meals that are easy to ingest can make eating less of a job. A patient with respiratory distress may need all of their energy to breath. Therefore, it is important to limit activities and provide rest. Resting before and after activity can make it more tolerable so patient can recover. A patient with recurring, seasonal, respiratory infections should identify

fowlers position when at rest.

semi fowler position and is partially upright most of the time.

Client will receive a snack or meal q4h.

Client is offered food q4h while awake and consumes 75 100%

Met. Ongoing.

Client will be able to rest before and after any activities.

Client is able to rest before Met. Ongoing. and after any activities.

Caregivers will verbalize conditions that may cause clients respiratory status

Cargivers continue to discuss exacerbating factors with health care

Partially met. Ongoing.

factors before discharge.

what is causing this problem. Reviewing current condition and history with parents and providers may help identify triggers for this patient. Being able to identify and treat the patient before her condition worsens may prevent future hospitalization.

to worsen before discharge.

providers.

Resources: Nursing Diagnosis Handbook Ninth Edition Ackley & Ladwig pgs. 192 196 Daviss Drug Guide