NANDA Diagnostic Statement: Ineffective airway clearance related to inability for patient to clear secretions and to evacuate very thick sputum from the respiratory tract to maintain a clear airway as evidenced by dyspnea, diminished breath sounds, orthopnea, adventitious breath sounds, and ineffective cough.
Behavioral Outcome / Goal: Patient will show effective airway clearance by being able to clear secretion with assistance and use of incentive spirometer, and effective cough.
-With assist x2, transport patient from bed to chair.
-Sitting position will improve patient breathing by decreasing dyspnea, orthopnea.
-Help patient breath deeply and cough effectively every 2 hours as needed
-To improve airway clearance by elimination of thick sputum.
-Remind patient to use a pillow to splint chest incision while coughing.
-improved coughing while protecting chest incision.
-Increase of fluid intake to loosen secretions.
-Decrease of sputum thickness.
-Auscultate for adventitious breath sounds.
-Decrease of scattered rhonchi.
-Assess pain level before breathing exercises.
-By keeping patient pain level low, she will be able to comply with deep breathing, coughing, and incentive spirometer use. -Ameliorate COPD condition and improve airway condition.
-Educate patient about the urge to quit smoking. Smoking cessation help telephone # given to patient's daughter.
Client Response: -Patient complained and cursed a lot but eventually complied with decrease of othopnea -After the first session she eliminated a thick yellowish mucus which she showed us in a paper towel. -She requested the pillow a couple of times to splint chest incision. -Client stated she had plans to quit cold turkey but did not promise. -Client showed improvement in breathing with decreased dyspnea and orthopnea. -With help she drunk 3 cups of cold water from lunch tray. -She stated a pain level of mostly 4/10 on a 0-10 level, Tylenol was enough to relieve her pain.
Summarize impressions of client progress toward outcomes / problem resolution: Client is progressing towards improving of airway. She was able to clear some secretion with assistance and goal is considered met as evidenced by the next day in clinical she stated: "I feel a lot better and my breathing feels improved."