Nursing diagnosis: ineffective airway clearance related to hypersecretion
characterized by a thick secretions or blood.
Objective:
- ffective airway clearance.
- Finding a comfortable position that allows increased air exchange.
- Demonstrate effective cough.
- Stated strategy to reduce the viscosity of secretions.
1. Explain to the client about the use of effective coughing and why there is a buildup of secretions in the respiratory tract.
Rationale: Knowledge that will hopefully help develop adherence to the treatment plan.
2. Teach the client about the proper method of controlling cough.
Rationale: Uncontrollable cough is exhausting and ineffective, causing frustration.
3. Breath deeply and slowly when sitting as upright as possible.
Rationale: Allows greater lung expansion.
4. Perform respiratory diaphragm.
Rationale: Respiratory diaphragm lower frequency of breath, and increased alveolar ventilacion.
5. Hold your breath for 3-5 seconds and then slowly remove as much as possible through the mouth. Do a second breath, hold it and batukan of the chest by two short and strong cough.
Rationale: Increasing the volume of air in the lung secretions facilitate spending.
6. Auscultation of the lungs before and after coughing clients.
Rationale: This helps evaluate the effectiveness.
7. Teach client action to reduce secretion: adequate hydration, increase fluid intake 1000 till 1500 cc / day if not contraindicated.
Rational: viscous secretion is difficult to dissolve and can cause blockage of mucus that leads to atelectasis.
8. Perform chest physio claping / vibrating.
Rationale: With a gravity discharge will come out to big and ease spending alveol secretions.
9. Collaboration with other health team physicians, radiology.
- Giving expectoran.
- Giving antibiotics.
- Consul thorax X-ray.
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