Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
Patient states
she has a 35 pack per year history of smoking.
Objective
RR 24 with basilar
rales and yellow sputum production, O2 sat = 90% on room air
Nonvisualization of portions of left hemidiaphragm is suspicious for left lower lobe acelectasis hx of
asthma and Albuterol Neb treatments every six hours on chart.
Obese
Post op procedure.
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Problem
Ineffective airway clearance
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Long Term:
Client will
demonstrate effective coughing and clear breath sounds by
the time of discharge.
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Auscultate breath
sounds q1 to 4 hours. Breath sounds are normally clear or scattered fine crackles
at bases, which clear with deep breathing. The
presence of coarse crackles during late inspiration indicates fluid in the airway;
wheezing indicates a narrowed airway (Simpson, 2006).
Monitor respiratory
patterns, including rate, depth, and effort. A
normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions
in the airway, the respiratory rate will increase (Simpson, 2006).
Teach the client
how to deep breathe and cough effectively. EB: Controlled
coughing uses the diaphragmatic muscles, making the cough more forceful and effective
(Donahue, 2002;
Nursing 2004).
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R/T
Asthma, obesity,
smoking.
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Short Term:
Client will
maintain a patent airway at all times during shift on 04.07.09 to be assessed at
1300.
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Teach importance
of not smoking. Be aggressive in approach, ask to set a date for smoking cessation,
and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking
cessation programs, and encourage clients who relapse to keep trying to quit. All healthcare clinicians should be aggressive in helping
smokers quit (CDC, 2007). EB: The combination of nicotine therapy and
an intensive, prolonged relapse prevention program are effective in promoting long-term
abstinence from smoking (Wagena et al, 2004).
Provide postural
drainage, percussion, and vibration only as ordered. EB:
There is no advantage of chest physiotherapy over
other airway clearance techniques for cystic fibrosis clients (Main, Prasad & van der Schans, 2005).
There is not enough evidence to support or refute the use of bronchial hygiene physical
therapy in COPD or bronchiectasis clients (Jones & Rowe, 2000).
Encourage the
client to use an incentive spirometer. The incentive
spirometer is an effective tool that can help prevent atelectasis and retention
of bronchial secretions (Guimares & Atallah, 2007).
EB: A study of postoperative abdominal surgery clients demonstrated that
coughing and deep breathing clients vs. use of an incentive spirometer resulted
in no significant difference in oxygenation (Genc et al, 2004).
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