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NURSING DIAGNOSIS: Ineffective Airway Clearance Related to Viscous Secretions and Shallow Chest Expansion Secondary to
Deficient Fluid Volume, Pain, and Fatigue
DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS RATIONALE
Respiratory Status: Gas exchange Monitor respiratory status q4h: rate, To identify progress toward or deviations from goal. Ineffective
[0402], as evidenced by depth, effort, skin color, mucous Airway Clearance leads to poor oxygenation, as evidenced by
■ Absence of pallor and cyanosis membranes, amount and color of pallor, cyanosis, lethargy, and drowsiness.
(skin and mucous mem- sputum.
branes) Monitor results of blood gases,
■ Use of correct chest x-ray studies, and incentive
breathing/coughing technique spirometer volume as available.
after instruction Monitor level of consciousness.
■ Productive cough Auscultate lungs q4h. Inadequate oxygenation causes increased pulse rate. Respira-
■ Symmetric chest excursion of Vital signs q4h (TPR, BP, pulse tory rate may be decreased by narcotic analgesics. Shallow
at least 4 cm oximetry). breathing further compromises oxygenation.
Within 48–72 hours
■ Lungs clear to auscultation Instruct in breathing and coughing To enable client to cough up secretions. May need encour-
■ Respirations 12–22/min; techniques. Remind to perform, agement and support because of fatigue and pain.
pulse, 100 beats/min and assist q3h.
■ Inhales normal volume of air Administer prescribed expectorant; Helps loosen secretions so they can be coughed up and ex-
on incentive spirometer schedule for maximum effective- pelled.
ness. Maintain Fowler’s or semi- Gravity allows for fuller lung expansion by decreasing pressure
Fowler’s position. of abdomen on diaphragm.
Administer prescribed analgesics. Controls pleuritic pain by blocking pain pathways and altering
Notify physician if pain not relieved. perception of pain, enabling client to increase thoracic expan-
sion. Unrelieved pain may signal impending complication.
* The NOC # for desired outcomes are listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a
sample of those suggested by NOC and NIC and should be further individualized for each client.
continued
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DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS RATIONALE
Administer oxygen by nasal cannula Supplemental oxygen makes more oxygen available to the
as prescribed. Provide portable oxy- cells, even though less air is being moved by the client,
gen if client goes off unit (e.g., for thereby reducing the work of breathing.
x-ray examination).
Assist with postural drainage daily Gravity facilitates movement of secretions upward through
at 0930. the respiratory passage.
Administer prescribed antibiotic to Resolves infection by bacteriostatic or bactericidal effect, de-
maintain constant blood level. pending on type of antibiotic used. Constant level required to
Observe for rash and GI or other prevent pathogens from multiplying.
side effects. Allergies to antibiotics are common.
NURSING DIAGNOSIS: Deficient Fluid Volume: Intake insufficient to replace fluid loss (See standardized care plan for
Deficient Fluid Volume, Figure 13-4).
NURSING DIAGNOSIS: Anxiety related to difficulty breathing and concern about work and parenting roles.
DESIRED OUTCOMES*/
INDICATORS NURSING INTERVENTIONS RATIONALE
Anxiety control [1402], as evi- When client is dyspneic, stay with Presence of a competent caregiver reduces fear of being un-
denced by her; reassure her you will stay. able to breathe.
■ Listening to and following in-
Remain calm; appear confident. Control of anxiety will help client to maintain effective breath-
structions for correct breathing
ing pattern.
and coughing technique, even Encourage slow, deep breathing.
during periods of dyspnea Reassures client the nurse can help her.
When client is dyspneic, give brief
■ Verbalizing understanding of
explanations of treatments and Focusing on breathing may help client feel in control and de-
condition, diagnostic tests, and
procedures. crease anxiety.
treatments (by end of day)
■ Decrease in reports of fear and When acute episode is over, give Anxiety and pain interfere with learning. Knowing what to ex-
anxiety detailed information about nature pect reduces anxiety.
■ Voice steady, not shaky of condition, treatments, and tests.
■ Respiratory rate of 12–22/min
Awareness of source of anxiety enables client to gain control
■ Freely expressing concerns and
As client can tolerate, encourage to over it. Husband’s continued absence would constitute a
possible solutions about work express and expand on her con- defining characteristic for this nursing diagnosis.
and parenting roles Explore al- cerns about her child and her work.
ternatives as needed.
* The NOC # for desired outcomes is listed in brackets following the appropriate outcome. Outcomes, interventions, and activities selected are only a
sample of those suggested by NOC and NIC and should be further individualized for each client.