Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient states she has a 35 pack per year history of smoking.

Objective

RR 24 with basilar rales and yellow sputum production, O2 sat = 90% on room air

Nonvisualization of portions of left hemidiaphragm is suspicious for left lower lobe acelectasis hx of asthma and Albuterol Neb treatments every six hours on chart.

Obese

Post op procedure.

Problem

Ineffective airway clearance

Long Term:

Client will demonstrate effective coughing and clear breath sounds by  the time of discharge.

Auscultate breath sounds q1 to 4 hours. Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates a narrowed airway (Simpson, 2006).

Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase (Simpson, 2006).

Teach the client how to deep breathe and cough effectively. EB: Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Donahue, 2002; Nursing 2004).

R/T

Asthma, obesity, smoking.

Short Term:

Client will maintain a patent airway at all times during shift on xxxx to be assessed at 1300.

Teach importance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. All healthcare clinicians should be aggressive in helping smokers quit (CDC, 2007). EB: The combination of nicotine therapy and an intensive, prolonged relapse prevention program are effective in promoting long-term abstinence from smoking (Wagena et al, 2004).

Provide postural drainage, percussion, and vibration only as ordered. EB: There is no advantage of chest physiotherapy over other airway clearance techniques for cystic fibrosis clients (Main, Prasad & van der Schans, 2005). There is not enough evidence to support or refute the use of bronchial hygiene physical therapy in COPD or bronchiectasis clients (Jones & Rowe, 2000).

Encourage the client to use an incentive spirometer. The incentive spirometer is an effective tool that can help prevent atelectasis and retention of bronchial secretions (Guimares & Atallah, 2007). EB: A study of postoperative abdominal surgery clients demonstrated that coughing and deep breathing clients vs. use of an incentive spirometer resulted in no significant difference in oxygenation (Genc et al, 2004).

AEB

Treatment on Albuterol and suspicious for atelectasis.