The document provides a rationale for 8 nursing interventions in a care plan for ineffective airway clearance. It also lists concepts in Column A and their matching descriptions in Column B. The interventions aim to promote deep breathing, coughing, hydration and monitoring of respiratory status. The concepts matched include tracheostomy, oxygen therapy, hypoxemia, incentive spirometry and assessments for need to suction.
The document provides a rationale for 8 nursing interventions in a care plan for ineffective airway clearance. It also lists concepts in Column A and their matching descriptions in Column B. The interventions aim to promote deep breathing, coughing, hydration and monitoring of respiratory status. The concepts matched include tracheostomy, oxygen therapy, hypoxemia, incentive spirometry and assessments for need to suction.
The document provides a rationale for 8 nursing interventions in a care plan for ineffective airway clearance. It also lists concepts in Column A and their matching descriptions in Column B. The interventions aim to promote deep breathing, coughing, hydration and monitoring of respiratory status. The concepts matched include tracheostomy, oxygen therapy, hypoxemia, incentive spirometry and assessments for need to suction.
The document provides a rationale for 8 nursing interventions in a care plan for ineffective airway clearance. It also lists concepts in Column A and their matching descriptions in Column B. The interventions aim to promote deep breathing, coughing, hydration and monitoring of respiratory status. The concepts matched include tracheostomy, oxygen therapy, hypoxemia, incentive spirometry and assessments for need to suction.
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AUBREY ROSE A.
VIDON
BSN 3Y1 - 2
1. Give the rationale for each of the following nursing interventions and selected activities for the nursing care plan for ineffective airway clearance: (20 pts)
INTERVENTIONS RATIONALE
1. Encourage the client to take several
It promotes oxygenation before controlled coughing. deep breaths
2. Encourage the client to take a deep This moves air down to the bottom areas of the lungs breath, hold for 2 seconds, and cough and opens up the air passages and moves the mucous two or three times in succession out; coughing is also easier.
3. Encourage use of incentive This incentive spirometer is a hand-held breathing
spirometry, as appropriate exercise device to help the patient breathe deeply.
Adequate fluid intake enhances dissolving of
4. Promote systemic fluid hydration, as pulmonary secretions and facilitates expectoration of appropriate mucus.
5. Monitor rate, rhythm, depth, and
Provides a basis for evaluating adequacy of ventilation. effort of respirations
6. Note chest movement, watching for
Presence of nasal erupting and utilization of symmetry, use of accessory muscles, embellishment muscles of breaths may happen in light and supraclavicular and intercostal of incapable ventilation. muscle retractions
It is important to distinguish normal respiratory sounds
7. Auscultate lung sounds after from abnormal ones for example crackles, wheezes, treatments to note results and pleural rub in order to make correct diagnosis.
8. Monitor client’s respiratory Assists in evaluating prescribed treatments and client secretions outcomes
Respiratory tract infections alter the amount and
9. Monitor client’s ability to cough character of secretions. An ineffective cough effectively compromises airway clearance and prevents mucus from being expelled 10. Monitor for increased restlessness, These clinical manifestations would be early indicators anxiety, and air hunger of hypoxia
2. Match the following concepts with each other. Write the letter only. Use CAPITAL letters. (2 points each)
ANSWER COLUMN A COLUMN B
A. Upper airway obstruction, upper airway bleeding,
inability to clear lower airway secretions, laryngeal or E 1. Tracheostomy tracheal fracture, airway burns, need for continuous ventilation, decreased LOC with inability to protect airway
B. Nasal cannula, face mask, non-rebreather, partial
B 2. Oxygen Therapy non-rebreather, venture mask, face tent
3. Assessments for need to C. Reduced oxygen in the blood characterized by a low A suction PO2 or Sa02
D. Percussions over congested areas can mechanically
C 4. Hypoxemia dislodge tenacious secretions from the bronchial walls
E. Surgical opening into the trachea with the creation
F 5. Incentive Spirometry of a stoma F. Improve pulmonary ventilation, counteract the effects of anesthesia/hypoventilation, loosen G 6. Tracheostomy precautions respiratory secretions, facilitate respiratory gaseous exchange, expand collapsed alveoli
G. Keep duplicate tract tube with obturator at bedside,
keep foreign objects such as aerosols and powders 7. Indications for H away from trach, provide humidified air and 02, keep Tracheostomy the stomata dry, good oral and nasal hygiene, medical/ surgical asepsis
H. Restlessness, gurgling sounds during respiration,
adventitious breath sounds when chest is auscultated, B 8. Chest Percussion change in mental status, skin color, rate and pattern of respiration, pulse rate and rhythm
