Nursing Diagnosis: Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.
Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.
Intervention and Rationale:
I. Assess for:
- Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
- Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
- Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.
- ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.
- Oxygen therapy via cannula - maintain optimal oxygen level.
- Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
- Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
- Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.
- Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
- Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
- Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
- Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
- Postural drainage and percussion PRN - mobilizes secretion.
- Suction secretions if cough ineffective - removal if unable to bring up secretions.
- Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.