Nursing Diagnosis Ineffective Airway Clearance related to thick secretions.
Goal: Cleanliness effective airway
- Finding a comfortable position that allows increased air exchange.
- Demonstrated effective cough.
- Stated strategy to reduce the viscosity of secretions.
Plan of Action:
1. Explain clients about the effective use of cough and why there is a buildup of secretions in the ward. breathing.
R / knowledge that will hopefully help develop client adherence to treatment plans.
2. Teach your clients about the proper method of controlling cough.
R / Uncontrollable cough is exhausting and ineffective, causing frustration.
3. Breath deeply and slowly when sitting as upright as possible.
R / Allows greater lung expansion.
4. Perform diaphragmatic breathing.
R / Respiratory diaphragm lower frequency. breathing and improve alveolar ventilation.
5. Hold your breath for 3-5 seconds and then slowly, remove as much as possible through the mouth.
Make a second breath, hold it and cough from the chest by two short and strong cough.
R / Increase the volume of air in the lung secretions facilitate secretion spending.
6. Auscultation of the lungs before and after coughing clients.
R / This helps evaluate the effectiveness of cough effort clients.
7. Teach client action to reduce the viscosity of secretions: maintain adequate hydration; increase fluid intake 1000 to 1500 cc / day if not contraindicated.
R / secretion is difficult to dilute thick and can cause blockage of mucus, which leads to atelectasis.
8. Encourage or provide good oral care after coughing.
R / Hiegene good oral increase the sense of well-being and prevent bad breath.
9. Collaboration with other health team:
By physicians, radiology and physiotherapy.
· Giving expectoran.
· Giving antibiotics.
· Consul-ray photo.
R / Expextorant to facilitate mucus and evaluation of client improvement of lung development.