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Nursing Care Plan Cues and Evidences Subjective Cues: No verbal cues reported Objective Cues: - Adventitious breath

sounds - Cough ineffective - Changes in respiratory rhythm - Restlessness Nursing Diagnosis Ineffective Airway Clearance related to obstructed airway and infection secondary to acute respiratory failure secondary to septic shock. Objectives Interventions 1. To maintain adequate airway. a. Monitor respirations and breath sounds, noting rate and sounds. b. Evaluate clients cough/gag reflex and swallowing ability. c. Position head appropriate for age/condition. d. Suction naso/trachea/oral prn Rationale Evaluation Value Integration

After 3 days of continuous care, the patient will be able to: 1. Maintain airway patency. 2. Expectorate or clear secretions readily. 3. Demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange.

e. Elevate head of bed/ change position every 2 hours and prn.

f.

Assist with procedures (bronchoscopy, tracheostomy) g. Keep environment allergen free. 2. To mobilize secretions a. Encourage deep breathing and coughing exercises. b. Administer analgesics. c. Give expectorants/

a. Indicative of respiratory distress and or accumulations of secretions. b. To determine ability to protect own airway. c. To open or maintain open airway in at rest or compromised individual. d. To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow or cough effectively. e. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage/ ventilation to lung segments. f. To clear/ maintain open airway. g. Dust, feathers, pillows and smokes can cause obstruction. a. To maximize effort. b. To improve cough when pain is inhibiting effort.

After 3 days of care, the patient was able to: 1. Maintain airway patency. 2. Expectorate or clear secretions readily. 3. Demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange.

Patience Understanding Perseverance

bronchodilators as ordered. d. Increase fluid intake, provide warm liquids, supplemental humidification (nebulizer). e. Assist with use of respiratory devices and treatments (mechanical ventilation). f. Position appropriately and discourage use of oil-based products around the nose. 3. To assess changes, note complications Auscultate breath sound and assess air movement. Monitor vital signs, noting blood pressure/ pulse changes. Observe for signs of respiratory distress (increased rate, restlessness/ anxiety, use of accessory muscle for breathing) Obtain sputum specimen, preferably before antimicrobial therapy is initiated. Monitor serial chest x-rays/ ABG/ pulse oximetry readings.

d.Hydration can help liquefy viscous secretions and improve secretion clearance. e. Various modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. f. To prevent vomiting with aspiration into lungs.

a. b. c.

a. To ascertain status and note progress.

d.

d. To verify appropriateness therapy.

e.

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