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    ICU NCP Airway

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    Lisa Tandog
    The patient was producing thick, yellowish sputum in a moderate amount, which was accumulating in the airways and causing respiratory distress. The nursing interventions included positioning the patient with high back rest to improve breathing, monitoring vital signs and respiratory rate, suctioning secretions as needed, increasing fluid intake, performing physiotherapy, administering medications, and documenting findings. The goal of care was to improve the patient's respiratory status and clear the airways of secretions by the end of the shift.

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    ICU NCP Airway

    Uploaded by

    Lisa Tandog
    401 views3 pages
    The patient was producing thick, yellowish sputum in a moderate amount, which was accumulating in the airways and causing respiratory distress. The nursing interventions included positioning the patient with high back rest to improve breathing, monitoring vital signs and respiratory rate, suctioning secretions as needed, increasing fluid intake, performing physiotherapy, administering medications, and documenting findings. The goal of care was to improve the patient's respiratory status and clear the airways of secretions by the end of the shift.

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    ICU Ncp Airway

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    The patient was producing thick, yellowish sputum in a moderate amount, which was accumulating in the airways and causing respiratory distress. The nursing interventions included positioning the patient with high back rest to improve breathing, monitoring vital signs and respiratory rate, suctioning secretions as needed, increasing fluid intake, performing physiotherapy, administering medications, and documenting findings. The goal of care was to improve the patient's respiratory status and clear the airways of secretions by the end of the shift.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    401 views3 pages

    ICU NCP Airway

    Uploaded by

    Lisa Tandog
    The patient was producing thick, yellowish sputum in a moderate amount, which was accumulating in the airways and causing respiratory distress. The nursing interventions included positioning the patient with high back rest to improve breathing, monitoring vital signs and respiratory rate, suctioning secretions as needed, increasing fluid intake, performing physiotherapy, administering medications, and documenting findings. The goal of care was to improve the patient's respiratory status and clear the airways of secretions by the end of the shift.

    Copyright:

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    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    Date & Time F E B R U A R Y O>

    Cues

    Nee d thick, A T I V of I

    Nursing Diagnosis

    Objectives of Care

    Nursing Interventions

    Evaluation

    Ineffective

    airway That within my 8 1.Monitor span of especially the RR. indicative

    VS, February 2012 of

    24,

    yellowish colored C sputum >moderate amount

    clearance related to hours thick secretions as care, manifested inability to cough. R: Mucus production by airway

    patients R: Changes in the RR @ 7 AM clearance are

    will be improved respiratory distress that GOAL MET as manifested by: may be due to the accumulation of secretions. upon to high back rest. Allows normal lung the expansion, breath upon diaphragm and sounds respiration of At the end of my 8 hours span of care, 2.Position in moderate airway improves patients was as

    sputum collected T upon suctioning. >crackles heard Y

    in the airways is a.Absence normal. Without it, crackles airways become foreign may dry may respiration and pass within the

    2 3 2 0 1 2

    on fields

    both

    lung upon E X

    organisms b.Respiratory rate R: easily

    maximum evidenced by:

    auscultation and respiration

    through. sometimes in excess

    But range of 16-21cpm decreases pressure in a.Clear prevents aspiration.

    >slightly labored E breathing >inability R C to I out S

    mucus produced is c.Decreased and amount of sputum

    changes in nature. accumulated in the 3.Change This results in the airway urge to cough and every 2 hours.

    position b.RR of 20 cpm

    11

    cough

    R: Enhances drainage c.Decreased

    secretions P M >respiratory rate of 30cpm

    expectorate Coughing is

    this a that

    of

    secretions

    and amount secretions through

    of

    mucus as sputum. P A >With an RLS of T 5 and GCS of 6 >WBC 20.9 February 2012 >Fluimucil 600mg 6am >with endotracheal tube attached to mechanical ventilator. in glass water OD result 10^9/L21, T E R N natural from capacity leads mucus blockage airway. Source: Richardson, Marion (2008) The Physiology the System. Nursingtimes.net of in to reflex

    ventilation to different accumulated lung segments.

    protects our lungs irritants. cough to which Disturbance in the

    4.Suction secretions as suctioning needed. R: To clear the accumulated excessive, viscous secretions that block the airway. 5.Increase fluid intake as prescribed by the physician. R: Hydration helps liquefy viscous sputum. 6.Perform physiotherapy. R: Vibration, percussion and postural drainage facilitates in the chest necessary

    as

    accumulation of this eventually creates a the

    Mucus Production in Respiratory

    loosening of secretions for expectoration. 7.Administer medications as ordered. R: Pharmacological to help management clear airways. 8.Document assessment accurately findings noting VS easier

    abnormalities, dyspneic episodes and changes in the color, amount & consistency of sputum. R: To identify infectious process and give prompt intervention

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