CHAPTER 48 / Oxygenation 1329
CONCEPT MAP Ineffective Airway Clearance
• ↑ temperature; fatigue; rapid, labored
respirations; mild dehydration. "Bad cold"
x several weeks. Dieting for several months
& skipping meals. Works full-time job as
secretary, college classes 2x/week.
Smokes, 21 pack/years.
• Assist to a sitting position with head slightly flexed,
shoulders relaxed, and knees flexed
• Encourage her to take several deep breaths
• Encourage her to take a deep breath, hold for 2
seconds, and cough two or three time in succession
• Encourage use of incentive spirometry, as appropriate
• Promote systemic fluid hydration, as appropriate
• Instruct about importance of leaving oxygen delivery
device on
• Periodically check oxygen delivery device to ensure
that the prescribed concentration is being delivered
• Observe for signs of oxygen-induced hypoventilation
• Monitor rate, rhythm, depth, and effort of respirations
• Note chest movement, watching for symmetry, use of
accessory muscles, and supraclavicular and intercostal
muscle retractions
• Auscultate breath sounds, noting areas of decreased or
absent ventilation and presence of adventitious sounds
• Auscultate lung sounds after treatments to note results
• Monitor client's ability to cough effectively
• Monitor client's respiratory secretions
• Institute respiratory therapy treatments (e.g., nebulizer)
as needed
• Monitor for increased restlessness, anxiety, and air
hunger
• Note changes in SaO2, and tidal CO2, and changes
in arterial blood gas values, as appropriate
Outcome partially met
• Coughs and deep breaths purposefully q1–2hr during the day
• Fluid intake ~1500 mL/day
• Cough productive of moderately thick, rusty-colored sputum
• Inspiratory crackles remain present in right lower lobe
• PaO2 is 85 mm Hg
Respiratory Status: Airway Patency aeb
• Fever not present
• Respiratory rate in expected range
• Moves sputum out of airway
• Free of adventitious breath sounds
• Height: 167.6 cm (5'6")
• Weight: 54.4 kg (120 lb)
• TPR, 39.4C (103F), BP: 28, 24,118/70
• Skin pale; cheeks flushed; chills;
nasal flaring; use of accessory
muscles; inspiratory crackles with
diminished breath sounds right base;
thick, yellow sputum
• Chest x-ray: right lobar
infiltration
• WBC: 14,000
• pH: 7.49
• PaCO2: 33 mm Hg
• HCO3-: 20 mEq/L
• PaO2: 80 mm Hg
JS
39 y.o.
Pneumonia
Ineffective Airway Clearance r/t thick
sputum, secondary to pneumonia, and
fatigue (aeb rapid respirations, nasal
flaring, and adventitious breath sounds)
Assessment
Legend: Nursing Diagnosis Outcomes Nursing Interventions Activities Evaluation/Reassessment
Cough Enhancement
Respiratory Monitoring
Oxygen Therapy
