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Objective Ineffective After 8 Independent: Effectiveness
- pale in airway hours of • Assess airway for >Maintaining the - Was the
appearance clearance nursing patency. airway is always the patient able to
- dyspnea related to intervention first priority, maintain
- uses ineffective s, the especially in cases of patent airway?
accessory cough patient's trauma, acute -Was the
muscles secretions neurological patient able to
when will be decompensation, or mobilize her
breathing mobilized • Auscultate lungs for cardiac arrest. secretions?
- productive and airway presence of normal -Was the
cough will show or adventitious patient able to
- RR=41 decreased breath sounds, as in have patent
cycles per in the following: airway?
minute secretions o Decreased or
absent breath Adequacy
>These may indicate
sounds -Was all the
presence of mucus
plug or other major
airway obstruction.
o Wheezing interventions
>These may indicate
are enough in
increasing airway
achieving and
o Coarse sounds maintaining
>These may indicate
patent airway?
presence of fluid
-Was all the
along larger airways.
resources of
• Assess respirations; the nurse like
>Abnormality time and effort
note quality, rate, indicates respiratory
pattern, depth, are enough?
flaring of nostrils,
dyspnea on Appropriaten
exertion, evidence
of splinting, use of -Was the
accessory muscles,
and position for mentioned are
applicable and
beneficial to
>Increasing the patient?
• Assess changes in
mental status. lethargy, confusion,
restlessness, and/or
irritability can be
early signs of Acceptability
cerebral hypoxia. - Was the
family willfully
• Assess cough for accepted the
effectiveness and >Consider possible
causes for interventions
productivity. done to the
ineffective cough
(e.g., respiratory patient.
muscle fatigue,
• Note presence of bronchospasm, or
sputum; assess thick tenacious
quality, color, secretions).
amount, odor, and
consistency. >This may be a
result of infection,
bronchitis, chronic
smoking, or other
condition. A sign of
infection is
discolored sputum
• Assist patient in (no longer clear or
performing white); an odor may
coughing and be present.
maneuvers. >These improve
• Instruct patient in productivity of the
the following: cough.
o Optimal
(sitting position) >Directed coughing
o Use of pillow or techniques help
hand splints mobilize secretions
when coughing from smaller airways
o Use of to larger airways
abdominal because the
muscles for coughing is done at
more forceful varying times. The
cough sitting position and
o Use of quad and splinting the
huff techniques abdomen promote
o Use of incentive more effective
spirometry coughing by
o Importance of increasing
ambulation and abdominal pressure
frequent and upward
position diaphragmatic
changes movement.

• Use positioning (if

tolerated, head of
bed at 45 degrees;
sitting in chair,
>These promote
• Encourage oral better lung
intake of fluids expansion and
within the limits of improved air
cardiac reserve. exchange.

>Increased fluid
intake reduces the
viscosity of mucus
• Demonstrate and produced by the
teach coughing, goblet cells in the
deep breathing, and airways. It is easier
splinting for the patient to
techniques. mobilize thinner
secretions with
• Administer >Patient will
medications: understand the
o Mucolytics (e.g. rationale and
Guaifenesin) appropriate
techniques to keep
the airway clear of
o Bronchodilators difficulties by
(e.g. Albuterol) hydrolyzing
tending to break
Collaborative: down/lower the
• Consult respiratory viscosity of mucin-
therapist for chest containing body
physiotherapy and secretions/compone
nebulizer nts, thereby
treatments as dissolving thick
indicated (hospital mucus.
and home >Reduces resistance
care/rehabilitation in the respiratory
environments). airway and increases
airflow to the lungs.

includes the
techniques of
postural drainage
and chest percussion
to mobilize
secretions in smaller
airways that cannot
be removed by
coughing or