The other diagnoses would be appropriate for a patient with an acute asthma exacerbation and respiratory distress, but they are not the priority. ineffective breathing pattern would be related to the breathing pattern is it too fast, too slow, shallow, accessory muscles being used, purse lip breathing? Anxiety adds to oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn increases anxiety. Oxygen saturation should be maintained at 90% or greater. Fatigue is a contributing factor to ineffective coughing. ineffective airway clearance would be a nonproductive congestive cough or inability to clear sputum. Otherwise, scroll down to view this completed care plan. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. Ineffective Breathing Pattern Nursing Diagnosis & Care Plan, Impaired Physical Mobility Nursing Diagnosis & Care Plan, Failing Nursing School? It involves airway inflammation and periodic narrowing of airway lumina (hyperreactivity). Note cough for efficacy and productivity. Nursing assessment and intervention are the keys to maintaining airway patency in the patient with an artificial airway in place. The most convenient way to remove most secretions is coughing. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Assess hydration status: skin turgor, mucous membranes, tongue. airway clearance, ineffective a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as inability by an individual to clear secretions or obstructions from the respiratory tract to maintain a clear airway. This nursing diagnosis for asthma is due to the presence of mucus in â¦ Ineffective airway clearance related to excess tenacious mucus; Therapeutic Intervention / Medical Management Treatment for lung problems includes: Antibiotics to prevent and treat lung and sinus infections. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. Respirations fall below 12 breaths per minute depending on the age of patient. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). Refer for home health aide services for assist with ADLs. Perform cardiopulmonary resuscitation (CPR) maneuvers for patients with complete airway obstruction. Our ultimate goal is to help address the nursing shortage by inspiring aspiring nurses that a career in nursing is an excellent choice, guiding students to become RNs, and for the working nurse â helping them achieve success in their careers! Lethargy and somnolence are late signs. Patient will recognize the significance of changes in sputum to include color, character, amount, and odor. Provide opportunity for return demonstration. Ineffective Airway Clearance is a common NANDA nursing diagnosis for pneumonia nursing care plans. Hill, A. T., Barker, A. F., Bolser, D. C., Davenport, P., Ireland, B., Chang, A. Groups of quick, shallow inspirations followed by regular or irregular periods of apnea (10 to 60 seconds). Educate caregivers in suctioning techniques. Ask yourself some serious questions. Oxygen therapy is recommended to improve oxygen saturation and reduce possible complications. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airwayâ¦ Effective coughing requires enough energy and may consume an extra effort to the patient. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. People with pneumonia commonly produce rust-colored, puru- lent sputum. When a problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it.
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