A D P I R E

Subjective Ineffective Airway STG: - Elevate the head of - Doing so would After 4 hours of nursing
Clearance Related After 4 hours of nursing the bed, change lower the diaphragm intervention the patient
According to the to Tracheal intervention the patient will be position frequently. and promote chest was able to display
health worker the bronchial able to display patent airway expansion, aeration patent airway with
client went to the inflammation, with breath sounds clearing and of lung segments, breath sounds clearing
Health Center for edema formation, absence of dyspnea mobilization, and and absence of dyspnea
consultation due increased sputum expectoration of
to fever and cough production secretions.
for more than 5 days.

Objective Teach and assist the

BP: 90/60 patient with proper
CR: 102 LTG: deep-breathing LTG:
O2 Sat: 91% exercises.
RR: 26 bpm After 8 hours of nursing Demonstrate proper After 8 hours of nursing
T: 38.5 intervention the patient will be splinting of the chest intervention the patient
able to demonstrate and effective was able to
coughing while in an demonstrate
 Behaviors to achieve upright position.
airway clearance. Encourage patient to  Behaviors to
do so often. achieve airway
 Patient will - facilitates maximum clearance.
display/maintain patent -Deep breathing expansion of the
airway with breath exercises  lungs and smaller  Patient will
sounds clearing; airways, and display/maintain
absence of dyspnea, improves the patent airway
cyanosis, as evidenced productivity of cough. with breath
by keeping a patent sounds clearing;
airway and effectively - is a reflex and a absence of
clearing secretions. natural self-cleaning dyspnea,
- Coughing mechanism that cyanosis, as
assists the cilia to evidenced by
 maintain patent keeping a patent
airways. It is the most airway and
helpful way to effectively
remove most clearing
secretions. secretions.

- reduces chest
- Splinting discomfort and an
upright position
favors deeper and
more forceful cough
effort making it more
effective.

- Stimulates cough or
- Suction as indicated: mechanically clears
frequent coughing, airway in a patient
adventitious breath who cannot do so
sounds, desaturation because of ineffective
related to airway cough or decreased
secretions. level of
consciousness. Note:
Suctioning can cause
increased hypoxemia;
hyper oxygenate
before, during, and
after suctioning.

- Maintain adequate - Fluids, especially

hydration by forcing warm liquids, aid in
fluids to at least 3000 the mobilization and
mL/day unless expectoration of
contraindicated (e.g., secretions. Fluids
heart failure). Offer help maintain
warm, rather than hydration and
cold, fluids. increases ciliary
action to remove
secretions, and
reduces the viscosity
of secretions. Thinner
secretions are easier
Assist and monitor to cough out.
effects of nebulizer
treatment and
another respiratory
physiotherapy:
incentive spirometer,
IPPB, percussion,
postural drainage.
Perform treatments
between meals and
limit fluids when
appropriate.

-  Nebulizers 

- humidify the airway

to thin secretions and
facilitates
liquefaction and
expectoration of
secretions.

- Postural drainage. - may not be as

effective in interstitial
 pneumonias or those
causing alveolar
exudate or
destruction

- Incentive spirometry - serves to improve

deep breathing and
helps prevent
atelectasis.

- Chest percussion - helps loosen and

mobilize secretions in
smaller airways that
cannot be removed
by coughing or
suctioning.
- Encourage
ambulation. - Helps mobilize
secretions and
reduces atelectasis.
Administer
medications, as
indicated:

- Mucolytics
- increase or liquefy
respiratory
secretions.

- Expectorants - increase productive

cough to clear the
airways. They liquefy
lower respiratory
 tract secretions by
reducing its viscosity.

- Bronchodilators - are medications

used to facilitate
respiration by dilating
the airways.

- Analgesics
- are given to
improve cough effort
by reducing
discomfort, but
should be used
cautiously because
they can decrease
cough effort and
depress respirations.
- Use humidified
oxygen or humidifier - Increasing the
at the bedside. humidity will
decrease the viscosity
of secretions. Clean
the humidifier before
use to avoid bacterial
growth.

- Monitor serial chest - Follows progress

x-rays, ABGs, pulse and effects and
oximetry readings. extent of pneumonia.
Therapeutic regimen
and may facilitate
 necessary alterations
in therapy. Oxygen
saturation should be
maintained at 90% or
greater. Imbalances
in PaCO2 and PaO2
may indicate
respiratory fatigue.

Assist with
bronchoscopy and/or
thoracentesis, if
indicated.

-Bronchoscopy - is occasionally
needed to remove
mucous plugs, drain
purulent secretions,
obtain lavage
samples for culture
and sensitivity.

- Thoracentesis - is done to drain

associated pleural
effusions and prevent
atelectasis.

- Anticipate the need - These measures are

for supplemental needed to correct the
oxygen or intubation hypoxemia.
if the patient’s Intubation is needed
condition for deep suctioning
deteriorates. efforts and provides a
source for
augmenting
oxygenation.

- Urge all bedridden - To promote full

and postoperative aeration and
patients to perform drainage of
deep breathing and secretions.
coughing exercises
frequently.
A D P I R E
Subjective Impaired Gas Exchange After 4 hours of - Maintain bedrest by - It prevents over After 4 hours of
related to Collection of nursing intervention planning activity and exhaustion and nursing intervention
According to the health mucus in airways the patient will be able rest periods to reduces oxygen the patient was able to
worker the client went to demonstrate minimize energy use. demands to facilitate demonstrate Improved
to the Health Center Improved ventilation Encourage the use of the resolution of ventilation and
for consultation due and oxygenation of relaxation techniques infection. Relaxation oxygenation of tissues
to fever and cough for tissues by ABGs within and diversional techniques help by ABGs within
more than 5 days. patient’s acceptable activities. conserve energy that patient’s acceptable
range and absence of can be used for range and absence of
Objective symptoms of effective breathing and symptoms of
BP: 90/60 respiratory distress. coughing efforts. respiratory distress.
CR: 102
O2 Sat: 91% - Elevate the head of - These measures
RR: 26 bpm the bed and encourage promote maximum
T: 38.5 frequent position chest expansion,
changes, deep mobilize secretions and
After 8 hours of breathing, and improve ventilation. After 8 hours of
nursing intervention effective coughing. nursing intervention
the patient will be able the patient was able to
to verbalized -Administer oxygen - The purpose of verbalized
therapy by appropriate oxygen therapy is to
 Maintain means: nasal prongs, maintain PaO2 above  Maintain
optimal gas mask, Venturi mask. 60 mmHg. Oxygen is optimal gas
exchange. administered by the exchange.
method that provides
 Patient will appropriate delivery Patient will participate
participate in within the patient’s in actions to maximize
actions to tolerance. Note: oxygenation.
maximize Patients with
oxygenation. underlying chronic lung
diseases should be
given oxygen
cautiously.

- Manifestations of
-Assess respirations: respiratory distress are
note quality, rate, dependent
rhythm, depth, use of on/indicative of the
accessory muscles, degree of lung
ease, and position involvement and
assumed for easy underlying general
breathing. health status as
patients adapt their
breathing patterns to
facilitate effective gas
 exchange. Rapid,
shallow breathing
patterns and
hypoventilation
directly affects gas
exchange. Hypoxia is
associated with signs
of increased breathing
effort. Tripod
positioning is evidence
of significant dyspnea.

- As oxygenation and
- Observe the color of perfusion become
skin, mucous impaired, peripheral
membranes, and nail tissues become
beds, noting the cyanotic. Cyanosis of
presence of peripheral nail beds may
cyanosis (nail beds) or represent
central cyanosis vasoconstriction or the
(circumoral). body’s response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes,
and skin around the
mouth (“warm
membranes”) is
indicative of systemic
hypoxemia.

- Restlessness,
- Assess mental status, irritation, confusion,
restlessness, and and somnolence may
changes in the level of reflect hypoxemia and
consciousness. decreased cerebral
oxygenation and
require further
intervention. Check
pulse oximetry results
with any mental status
changes in older
adults.

- Anxiety is a
- Assess anxiety level manifestation of
and encourage psychological concerns
verbalization of and physiological
feelings and concerns. responses to hypoxia.
Providing reassurance
and enhancing a sense
of security can reduce
the psychological
component, decreasing
oxygen demand and
adverse physiological
responses.

- Tachycardia is usually
- Monitor heart rate present due to fever
and rhythm, and blood and/or dehydration
pressure. but may represent a
response to hypoxemia
—initial hypoxia and
hypercapnia increase
BP and HR. As hypoxia
becomes more severe,
 BP may drop while HR
tends to be rapid with
dysrhythmias.

-High fever (common

in bacterial pneumonia
- Monitor body and influenza) greatly
temperature, as increases metabolic
indicated. Assist with demands and oxygen
comfort measures to consumption and
reduce fever and chills: alters cellular
addition or removal of oxygenation.
bedcovers,
comfortable room
temperature, tepid or
cool water sponge
bath. - Shock and pulmonary
edema are the most
- Observe for common causes of
deterioration in death in pneumonia
condition, noting and require immediate
hypotension, copious medical intervention.
amounts of bloody
sputum, pallor,
cyanosis, change in
LOC, severe dyspnea,
and restlessness. - It follows the progress
of the disease process
- Monitor ABGs, pulse and facilitates
oximetry. alterations in
pulmonary therapy.
Pulse oximetry detects
changes in
 oxygenation. O2 sats
should be at 90% or
greater.