Ineffective Airway Clearance - Nursing Care Plan for Hypoglycemia

Nursing Diagnosis and Interventions for Hypoglycemia

Ineffective Airway Clearance related to airway obstruction / increase in tracheobronchial secretions.

Defining characteristics :

• Dyspnoea.
• Orthopnea.
• Cyanosis.
• Crackles / crepitations.
• Difficulty speaking.
• Cough is ineffective or non-existent.
• Eyes widened.
• Increased sputum production.
• Restless.
• Changes in the frequency and rhythm of breathing.

NOC :

Goal : Effective airway

Outcomes :

• Respiration Status : Patency Road Breath :
• Breath sounds clean.
• No cyanosis.
• No shortness of breath / dyspnea.
• The rhythm of breathing and respiratory rate within normal range.
• Do not feel suffocated.
• No cyanosis.
• No agitated.
• Sputum is reduced.

Respiratory Status : Ventilation

• Demonstrate effective cough.
• Breath sounds were clean.
• No cyanosis.
• No dyspnoea (able to breathe more easily).
• No pursed lips.

NIC / Intervention

Airway Suctioning :

1. Ensure suctioning needs .
2. Auscultation of breath sounds before and after suctioning.
3. Inform the client and family about suctioning.
4. Asking clients a deep breath before suctioning.
5. Give oxygen by nasal cannula to facilitate nasotracheal suctioning.
6. Use sterile equipment every action.
7. Encourage clients a deep breath and rest after the catheter is removed from the nasotracheal.
8. Monitor the status of the client oxygen.
9. Stop suction when the client showed bradycardia.

Airway Management :

1. Open the airway, use techniques chin lift or jaw thrust if necessary.
2. Position the client to maximize ventilation.
3. Identification of the need for client installation artificial airway.
4. Attach the OPA if necessary.
5. Perform chest physiotherapy if necessary.
6. Remove secretions by coughing or suctioning.
7. Auscultation of breath sounds, note the presence of additional noise.
8. Collaboration of bronchodilators if necessary.
9. Monitor respiration and oxygen status.

Cough Enhancement :

1. Monitor lung function, vital capacity, and maximal inspiration.
2. Encourage the patient to do deep breathing, coughing arrested last 2 seconds 2-3 times.
3. Encourage clients a deep breath several times, released slowly and cough at the end of expiration.

Oxygen Therapy :

1. Clean the secret in the mouth, nose and trachea / throat.
2. Maintain airway patency.
3. Explain to the client / family about the importance of giving oxygen.
4. Give oxygen as needed.
5. Select the appropriate equipment needs : nasal cannula 1-3 l / min, head box 5-10 l / min , etc..
6. Monitor O2 flow.
7. Monitor O2 hose.
8. Periodically check the O2 hose, humidifier, O2 flow.
9. Observation O2 deficiency signs : restlessness, cyanosis, etc..
10. Monitor signs of poisoning O2.
11. Maintain O2 during transport.
12. Instruct client / family to observe the O2 supply, water humidifier, if the report finished guard.

Adjusting the position

• Adjust the position of the patient semi-Fowler , head extension .
• Tilt the head when vomiting .

Cchest Physiotherapy

1. Determine the presence of contraindications chest physiotherapy .
2. Determine lung segments that require chest physiotherapy .
3. Position the client with lung segments which require drainage placed higher .
4. Use a pillow to help position the head .
5. Combine techniques posturnal percussion and drainage .
6. Combine fibrasi and posturnal drainage techniques .
7. Manage inhalation therapy .
8. Manage administration of a bronchodilator , mucolytics .
9. Monitor and type of sputum .
10. Encourage coughing before and after posturnal drainage .