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Subjective:
Pt stated “I feel like I can’t breathe”
Pt stated “I can’t clear my throat. If I can
cough, it usually doesn’t help.”
Objective:
Pt demonstrates ineffective coughing.
Pt struggles for air.
Pt experiences a very flushed face after any activity including, turning, bathing,
and cleaning up.
Pt demonstrates a respiratory rate of 36 breaths per minute.
Pt’s respirations are very labored and non-even.
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Problem:
Ineffective Airway Clearance
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Long Term:
Pt will be able to verbalize the understanding
of appropriate measures to maintain a patent airway at all times by discharge.
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*Discuss and teach the pt the importance of performing coughing and deep breathing
exercises.
Rationale:
“This technique can help increase sputum clearance
and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making
the cough more forceful and effective.” (Ackley & Ladwig, 2008, p.125-126)
“Many patients with COPD have developed ineffective
coughing patterns that do not adequately clear their airways of sputum. The main
goals of effective coughing are to conserve energy, reduce fatigue, and facilitate
removal of secretions. (Lewis, 2007, p. 646)
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I
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Unable to evaluate pt goal due to confusion. Hypothetically, once the pt was oriented
again, I would have her verbalize her understanding of measures to take on her own
to maintain a patent airway.
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Unable to evaluate interventions to due to confusion. Although, the pt was able to
perform the coughing and deep breathing after demonstration by the staff, it is
unlikely that she would be able to do this on her own at this time. Right now, the
pt would need continuous reinforcement about how to perform the exercises with assistance
from the staff.
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R/T:
Inflammation
Presence of secretions
COPD
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Short Term:
Pt will demonstrate effective coughing and deep
breathing exercises within three days, by [Month] 6, [Year].
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*Reposition the pt at least once every two hours
to optimize respirations. Position the pt with the HOB upright at least 45 degrees
at all times.
Rationale:
“An upright position allows for maximal lung
expansion.” (Ackley & Ladwig, 2008, p. 125)
*Encourage coughing and deep breathing exercises.
Rationale:
***Same citations as long term goal!
(Ackley
& Ladwig, 2008, p.125-126)
(Lewis,
2007, p. 646)
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I
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Goal met. The pt demonstrated effective coughing
and deep breathing upon observation. After performing deep breathing exercises,
the pt’s O2 saturation increased from 93% to 95%.
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Continue interventions as listed. Reposition
the pt at least once every two hours with the HOB upright at least 45 degrees. Continue
to encourage coughing and deep breathing exercises to promote airway clearance and
appropriate O2 saturation.
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