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NCP Copd Airway

The document describes a patient case of ineffective airway clearance due to bronchoconstriction and increased mucus production from asthma. The patient presented with wheezing, crackles, barrel chest, restlessness, use of accessory muscles when breathing, sticky yellow secretions, productive cough, dyspnea, respiratory rate of 25 breaths per minute, and oxygen saturation of 87%. The nurse's goals were to minimize the patient's respiratory distress and normalize their vital signs within 2-4 days through interventions like diaphragmatic breathing exercises, chest physiotherapy, positioning, suctioning, nebulizers, oxygen, and medications as ordered by the physician. After 30 minutes, the patient's

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Sugar Capule - Manuel
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299 views2 pages

NCP Copd Airway

The document describes a patient case of ineffective airway clearance due to bronchoconstriction and increased mucus production from asthma. The patient presented with wheezing, crackles, barrel chest, restlessness, use of accessory muscles when breathing, sticky yellow secretions, productive cough, dyspnea, respiratory rate of 25 breaths per minute, and oxygen saturation of 87%. The nurse's goals were to minimize the patient's respiratory distress and normalize their vital signs within 2-4 days through interventions like diaphragmatic breathing exercises, chest physiotherapy, positioning, suctioning, nebulizers, oxygen, and medications as ordered by the physician. After 30 minutes, the patient's

Uploaded by

Sugar Capule - Manuel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Chinese General Hospital Colleges

PARAS, SARAH JANE P.


IVB1


ASSESSMENT DIAGNOSIS INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
Subjective:
As verbalized by the
client, inuubo ako,
marami akong plema.


Objective:
- (+) wheezes
- (+) crackles
- Barrel chest
- Restlessness
- Use of
accessory
muscles when
breathing
- Sticky yellow
secretions
- Productive
cough
- Dyspnea
- RR: 25cpm
- Oxygen
saturation: 87%



Ineffective airway
clearance related to
bronchoconstriction and
increased mucus
production as
manifested by:

Subjective:
As verbalized by the
client, inuubo ako,
marami akong plema.


Objective:
- (+) wheezes
- (+) crackles
- Barrel chest
- Restlessness
- Use of
accessory
muscles when
breathing
- Sticky yellow
secretions
- Productive
cough
- Dyspnea
- RR: 25cpm
- Oxygen
saturation: 87%
Irritates Goblet
cells and mucous
glands


Accumulation and
increased mucus
production



Ineffective Airway
Clearance

Short term:

After 20-30 minutes
of nursing
interventions, the
client will:

- Minimize use
of accessory
muscles
when
breathing
- Decrease RR
at least 21-23
cpm

Long Term:

After 2-4 days of
nursing interventions,
the client will:

- Absence of
use of
accessory
muscles
when
breathing
- Decrease RR
less than 20
Independent:
-Establish rapport with the
client


-Monitor vital signs
especially RR

-Teach and encourage the
use of diaphragmatic
breathing and cough
exercises



-Elevate head of bed,
place in semi-Fowlers to
high-Fowlers position

-Advised to do bronchial
tapping or chest
physiotherapy

- Increase fluid intake

- Assist in mobilization
and provide proper airway
support.



-To gain trust and
active cooperation
and participation

-To have a baseline
data

-To improve
ventilation and
mobilize secretions
without causing
breathlessness and
fatigue

-To maximize lung
expansion, sustain
open airway

-To loosen secretions
and for better
expectorations

-To liquefy secretions

- Giving assistance
may decrease the
effort in the side of
the patient, while
moving it is important
Short term:

After 30 minutes of
nursing interventions, the
client had:

- Minimized use of
accessory
muscles when
breathing
- Decreased RR at
22 cpm

Long Term:

After 2-4 days of nursing
interventions, the client
will:

- Absence of use
of accessory
muscles when
breathing
- Decreased RR at
20 cpm
- Increased oxygen
at 95%
- Maintain patency
of airway
Chinese General Hospital Colleges
PARAS, SARAH JANE P.
IVB1


cpm
- Increase
oxygen
saturation at
least 95% -
100%
- Maintain
patency of
airway





- Suction nasal or oral
secretions as indicated.



Dependent:
- Administer mucolytic,
bronchodilators as ordered
by the physician




-Administer antibiotics as
prescribed

-Nebulize every 6 hours

-Administer oxygen
to provide proper
oxygenation in order
to attain the desired
move

- Mechanically help
the patient breathe
easier. Always
observe sterile
technique

- Collaboration with
the physician in terms
of pharmacological
intervention is also
vital in providing
better outcomes.

-To prevent infections


-To liquefy secretions

-To help in breathing

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