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Ineffective Airway Clearance related to Asphyxia Neonatorum


Nursing Diagnosis :

Nursing Interventions : Ineffective airway clearance related to obstruction of mucus.

Nursing Outcomes:

Repiration status: Ventilation
Indicators:
  • Free of abnormal breath sounds.
  • No shortness of breath.
  • Respiration rate is within the normal range.
  • Regular respiratory rhythm.
  • No retraction of the chest.
Assessment scale:
  1. Extremely compromised.
  2. Substantially compromised.
  3. Moderately compromised.
  4. Mildly compromised.
  5. Not compromised.

Nursing Interventions

Airway management
  • Open the airway.
  • Position the patient to maximize ventilation.
  • Identification of patients need artificial airway appliance installation.
  • Remove secretions by suction.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status every 6 hours.
Vital sign monitoring
  • Monitor blood pressure, pulse, temperature, and respiration.
  • Monitor quantities and heart rhythm.
  • Monitors heart sounds.
  • Monitor lung sounds.
  • Monitor abnormal breathing patterns.
  • Monitor temperature, color, and moisture.
  • Monitor peripheral cyanosis.
  • Identify the causes of changes in vital signs.
Oxygen therapy
  • Setting up the oxygen equipment and a humidifier.
  • Provide supplemental oxygen by order.
  • Monitor the liter flow of oxygen.
  • Monitoring canule position.
  • Monitor signs of oxygen toxicity.

Rationale:
  • Patency of the airway is the main requirement to obtain adequate ventilation.
  • Helping lungs to meet the body's need for oxygen.
  • Assessing changes in status, to determine actions to improve / maintain the status respiration.

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