- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Decreased energy and fatigue
- Ineffective cough
- Tracheobronchial infection
- Tracheobronchial obstruction (including foreign body aspiration)
- Copious tracheobronchial secretions
- Perceptual/cognitive impairment
- Impaired respiratory muscle function
- Trauma
As evidenced by: [Check those that apply]
- Abnormal breath sounds (crackles, rhonchi, wheezes)
- Changes in respiratory rate or depth
- Cough
- Hypoxemia/cyanosis
- Dyspnoea
- Chest wheezing
Patient’s Diagnosis: –
Date:-
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- Maintain airway free of secretions.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess airway for patency. | Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest. |
| Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnoea on exertion, evidence of splinting, use of accessory muscles, position for breathing. | Abnormality indicates respiratory compromise. |
| Assess cough for effectiveness and productivity. | Consider possible causes for ineffective cough: respiratory muscle fatigue, severe bronchospasm, thick tenacious secretions, and others. |
| Note presence of sputum; assess quality, colour, amount, odour, and consistency. | May be a result of infection, bronchitis, chronic smoking, and others. A sign of infection is discoloured sputum (no longer clear or white); an odour may be present. |
| Monitor arterial blood gases (ABGs). | Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. |
| Assess for pain. | Postoperative pain can result in shallow breathing and an ineffective cough. |
| Assist patient in performing coughing and breathing manoeuvres. | To improve productivity of the cough. |
| Encourage oral intake of fluids within the limits of cardiac reserve. | To prevent drying of secretions. |
| Demonstrate and teach coughing, deep breathing, and splinting techniques. | So patient will understand the rationale and appropriate techniques to keep the airway clear of secretions. |
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