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.
- Extremely compromised.
- Substantially compromised.
- Moderately compromised.
- Mildly compromised.
- 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.
- 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.
- 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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