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Cues Nursing Analysis Goals and Nursing Rationale Evaluation

Diagnosis Objectives Interventions


Ineffectiv Coughing makes
Objective: e Airway breathing easier, opens Goal:
-Client clearance airways, and rids lungs -After 4 hours
gasping for related to of infected material. It of nursing
air thick, intervention,
also gives antibiotics
-client with viscous the client will
NGT and
more room to work. If be able to
-weak body bloody we don’t cough and demonstrate
movements secretions clear our airways absence/
-productive breathing can become reduction of
coughing with more difficult and the congestion
bloody normal exchange of with breath
secretions oxygen and carbon sounds clear,
-weak dioxide may be respirations
pulsation compromised. You may noiseless and
feel some shortness of improved
oxygen -Identify client -Persons with Was the client
breath if the airways and
exchange populations at impaired ciliary able to
lungs are not cleared of risk function; those maintain
excess mucus. Also, Objective: with excessive or adequate,
bacteria may be trapped -To maintain abnormal mucus patent airway?
in the lungs with the adequate, production ; those
potential for causing patent airway with impaired ___Yes___No
respiratory tract cough function; _______Why
infections. Repeated those with
episodes of infection swallowing
may result in lung abnormalities;
damage. immobility are all
at risk for problems
with maintenance
Effective airway of open airways
clearance, (also referred -Monitor -Indicative of
to as pulmonary or respirations and respiratory distress
respiratory hygiene or breath sounds, and/or
noting rate and accumulation of
therapy) is often an
sounds secretions
important part of the
overall treatment plan -Evaluate
for patients with NTM client’s -To determine
and especially for those cough/gag reflex ability to protect
with bronchiectasis. and swallowing own airway
Whether you have a ability
productive cough that
produces thick or -Position in
excessive sputum, or a semi- or high -The upright
dry unproductive cough Fowler’s position position enhances
lung expansion and
that does not produce
facilitates
sputum, airway ventilation with
clearance techniques -Assist with minimal effort
can help keep airways appropriate
clear and open by testing -To identify
inflating the airways and causative/precipita
helping to prevent ting factors
mucus from plugging -Suction
the small airways. naso/tracheal/or -to clear airway
al prn when excessive or
http://ntminfo.org/default_ viscous secretions
aspx/ are blocking airway
p/airway_clearance.aspx or client is unable
to swallow or
cough effectively
-Elevate head of
bed/ change -To take advantage
position every 2 of gravity
hours and prn decreasing
pressure on the
diaphragm and
enhancing
drainage of/
ventilation to
-Insert oral different lung
airway as segments
needed
-To maintain
antomic position of
tongue and natural
airway, especially
hen tongue/
laryngeal edema or Was the client
thick secretions able to
may block airway mobilize
-To mobilize -Instruct the secretions?
secretions client to take a _____Yes____N
deep breath -Coughing helps o
slowly and to move __________Why
hold it for 3 to 5 tracheobronchial
seconds, then secretions out of
exhale; to take a the lung. Deep
second breath breathing dilates
and then, while the airways,
exhaling, to stimulates
cough forcefully surfactant
twice production, and
expands lung
-When possible, tissue
schedule
coughing and
deep breathing -The less
sessions at postoperative pain
times when pain a client
medication is experiences, the
maximally more effective are
effective coughing and deep
breathing
-Administer
analgesics
-To improve cough
when pain is
-Assist with use inhibiting effort
of respiratory
devices and -Various therapies/
treatments modalities may be
required to
acquire/ maintain
adequate airways,
improve
respiratory
-Position function and gas
appropriately exchange
-To assess and discourage
changes, note use of oil-based -To prevent
complications products around vomiting with Was the client
nose aspiration into able to assess
lungs changes and
note
-Auscultate complications?
breath sounds ____Yes____No
and assess air _________Why
movement -To ascertain
status and note
-Observe for progress
signs/ symptoms
of infections

-To promote -Obtain sputum -To identify


wellness specimen, infectious
preferably process/promote
before timely intervention Was the client
antimicrobial able to
therapy is -To verify promote
initiated appropriateness of wellness?
therapy ___Yes ____No
_________Why
-Assess client’s/
SO’s knowledge
of contributing
causes, -Modalities to
treatment plan, manage secretions
specific and improve
medications, airflow vary
and therapeutic according to
procedures client’s diagnosis

-Provide
information
about the
necessity of -To report changes
raising and in color and
expectorating amount in the
secretions event that medical
versus intervention may
swallowing them be needed to
prevent/ treat
-Encourage/ infection
provide
opportunities for
rest; limit -Prevents/reduces
activities to fatigue
level of
respiratory
tolerance