Question

Give the rationale for each of the following nursing interventions and selected activities for the nursing care plan for ineffective airway clearance.

INTERVENTIONS

1.Encourage the client to take several deep breaths

Rationale:

2.Encourage the client to take a deep breath, hold for 2 seconds, and cough two or three times in succession

Rationale:

3.Encourage use of incentive spirometry, as appropriate

Rationale:

4.Promote systemic fluid hydration, as appropriate

Rationale:

5.Monitor rate, rhythm, depth, and effort of respirations

Rationale:

6.Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions

Rationale:

7.Auscultate lung sounds aftertreatments to note results

Rationale:

8.Monitor client’s respiratory secretions

Rationale:

9.Monitor client’s ability to cough effectively

Rationale:

10.Monitor for increased restlessness, anxiety, and air hunger

Rationale:

Match the following concepts with each other. Write the letter only. Use CAPITAL letters.

__1.Tracheostomy

__2.Oxygen Therapy

__3.Assessments for need to suction

__4.Hypoxemia

__5.Incentive Spirometry

__6.Tracheostomy precautions

__7.Indications for Tracheostomy

__8.Chest Percussion

CHOICES:

A. Upper airway obstruction, upper airway bleeding, inability to clear lower airway secretions, laryngeal or tracheal fracture, airway burns, need for continuous ventilation, decreased LOC with inability to protect airway

B.Nasal cannula, face mask, non-rebreather, partial non-rebreather, venture mask, face tent

C.Reduced oxygen in the blood characterized by a low PO2 or Sa02

D.Percussions over congested areas can mechanically dislodge tenacious secretions from the bronchial walls

E.Surgical opening into the trachea with the creation of a stoma

F.Improve pulmonary ventilation, counteract the effects of anesthesia/hypoventilation, loosen respiratory secretions, facilitate respiratory gaseous exchange, expand collapsed alveoli

G.Keep duplicate tract tube with obturator at bedside, keep foreign objects such as aerosols and powders away from trach, provide humidified air and 02, keep the stomata dry, good oral and nasal hygiene, medical/ surgical asepsis

H.Restlessness, gurgling sounds during respiration, adventitious breath sounds when chest is auscultated, change in mental status, skin color, rate and pattern of respiration, pulse rate and rhythm

Answer 1

INTERVENTIONS

1.Encourage the client to take several deep breaths

Rational: when the patient take deep breathing, it helps to increase the level of oxygen in the body and helps in removal of secretions from the respiratory tract.

2. Encourage the client to take a deep breath, hold for 2 seconds, and cough two or three times in succession

Rational: it helps to remove the obstructions and secretions in the airway tract and opens the airway passage. and improve the normal respiration pattern and increase the oxygen saturation level in the body.

3.Encourage use of incentive spirometry, as appropriate

Rationale: In the case of ineffective airway clearance, the incentive spirometry helps to remove the mucous and inprove the function of the lungs. along with that spirometry help to strengthen the lungs. Also it helps to keeps the lungs fluid free and active. The acumulation of fluid in the lungs leads to complications like COPD, pneumonia etc... these conditions leads to obstruct the normal lung functions. Another function is that,  it help to reduce the mucous buildup in the airway tract. Helps in pulmonary ventilation also.

4.Promote systemic fluid hydration, as appropriate

Rationale: The systemic fluid hydration helps in clearance of lower airway secretion and prevent the breathing difficulty.

MATCH THE FOLLOWING

Q1. E

Q2. B

Q3. H

Q4. C

Q5. F

Q6. G

Q7. A

Q8. D