Date & Time F E B R U A R Y O>

Cues

Nee d thick, A T I V of I

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

Ineffective

airway That within my 8 1.Monitor span of especially the RR. indicative

VS, February 2012 of

24,

yellowish colored C sputum >moderate amount

clearance related to hours thick secretions as care, manifested inability to cough. R: Mucus production by airway

patients R: Changes in the RR @ 7 AM clearance are

will be improved respiratory distress that GOAL MET as manifested by: may be due to the accumulation of secretions. upon to high back rest. Allows normal lung the expansion, breath upon diaphragm and sounds respiration of At the end of my 8 hours span of care, 2.Position in moderate airway improves patients was as

sputum collected T upon suctioning. >crackles heard Y

in the airways is a.Absence normal. Without it, crackles airways become foreign may dry may respiration and pass within the

2 3 2 0 1 2

on fields

both

lung upon E X

organisms b.Respiratory rate R: easily

maximum evidenced by:

auscultation and respiration

through. sometimes in excess

But range of 16-21cpm decreases pressure in a.Clear prevents aspiration.

>slightly labored E breathing >inability R C to I out S

mucus produced is c.Decreased and amount of sputum

changes in nature. accumulated in the 3.Change This results in the airway urge to cough and every 2 hours.

position b.RR of 20 cpm

11

cough

R: Enhances drainage c.Decreased

secretions P M >respiratory rate of 30cpm

expectorate Coughing is

this a that

of

secretions

and amount secretions through

of

mucus as sputum. P A >With an RLS of T 5 and GCS of 6 >WBC 20.9 February 2012 >Fluimucil 600mg 6am >with endotracheal tube attached to mechanical ventilator. in glass water OD result 10^9/L21, T E R N natural from capacity leads mucus blockage airway. Source: Richardson, Marion (2008) The Physiology the System. Nursingtimes.net of in to reflex

ventilation to different accumulated lung segments.

protects our lungs irritants. cough to which Disturbance in the

4.Suction secretions as suctioning needed. R: To clear the accumulated excessive, viscous secretions that block the airway. 5.Increase fluid intake as prescribed by the physician. R: Hydration helps liquefy viscous sputum. 6.Perform physiotherapy. R: Vibration, percussion and postural drainage facilitates in the chest necessary

as

accumulation of this eventually creates a the

Mucus Production in Respiratory

loosening of secretions for expectoration. 7.Administer medications as ordered. R: Pharmacological to help management clear airways. 8.Document assessment accurately findings noting VS easier

abnormalities, dyspneic episodes and changes in the color, amount & consistency of sputum. R: To identify infectious process and give prompt intervention