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Actual Nursing Diagnosis/Problem: Nursing Diagnosis/Problem:

ineffective airway clearance related to increased secretions and inflammations and inflammation second to pulmonary infiltrate

Predicted Patient Behavioral Outcome (Goal): the patient will demonstrate effective airway clearance by performing breathing exercises three times daily and using the incentive spirometer every hour while awake, resulting in a reduction of sputum production to less than 10 mL per day and improved lung sounds as noted in daily assessments.

1.Nursing Interventions: Assess respiratory status

Scientific Rationale:

assessing respiratory status in patients with increased secretions is essential for early detection of complications, evaluation of treatment efficacy, and ensuring optimal respiratory function

Actual patient response: patient describe feeling tightness in his chest and mention, "I’ve been coughing a lot, especially when I lie down." He also notes, "I sometimes feel like I’m not getting enough air, especially when I’m active." he express concern about his increased mucus production, stating, "It’s hard to clear my throat, and I feel like there’s something stuck in there."

evaluation:

The patient exhibits a respiratory rate of 23 breaths per minute, which is elevated, and oxygen saturation levels are at 91%, suggesting compromised oxygenation. Auscultation reveals bilateral wheezing, crackles and increased secretions, particularly in the lower lobes, indicating obstruction and inflammation. The patient reports persistent coughing, difficulty in clearing mucus, and a sensation of tightness in the chest. Additionally, the use of accessory muscles for breathing is observed, reflecting increased respiratory effort. Overall, these findings highlight the need for immediate interventions to improve airway clearance and enhance respiratory function, reinforcing the importance of ongoing monitoring and supportive care

2. Nursing intervention: Teach and encourage the patient to perform deep breathing exercises every hour to promote lung expansion and secretion clearance

Scientific rationale: Deep breathing exercises help expand the alveoli, increasing lung volumes and promoting better oxygenation. This can counteract the effects of atelectasis, which can occur due to secretions and inflammation (Bourbeau et al., 2011). Deep breathing also stimulates the mucociliary escalator mechanism, aiding in the movement of mucus toward the throat, where it can be coughed out. Increased tidal volume enhances the effectiveness of this natural process, reducing the risk of airway obstruction

Actual Patient response: The patient actively engages in the teaching session and demonstrates proper technique during the practice session. he expresses feeling more relaxed and less anxious after completing the deep breathing exercises

Evaluation: The intervention to teach and encourage deep breathing exercises was effective in promoting lung expansion and secretion clearance. The patient's positive responses and improvements in respiratory status confirm the success of the nursing intervention, emphasizing the importance of education and patient engagement in managing respiratory health. Continued monitoring and reinforcement of the exercises will support the patient’s ongoing recovery and self-management

3. Nursing intervention: Instruct the patient on the proper use of an incentive spirometer and encourage its use at least 10 times per hour while awake to improve lung function

Scientific rationale: incentive spirometer is grounded in its effectiveness in enhancing lung function and preventing respiratory complications, particularly in patients at risk for atelectasis or impaired airway clearance. By encouraging deep, sustained inhalations, the spirometer helps to expand the alveoli, improve ventilation-perfusion matching, and facilitate the mobilization of pulmonary secretions (Berglund et al., 2019). This not only enhances oxygenation and carbon dioxide elimination but also reduces the risk of atelectasis, especially in postoperative patients (Cleveland et al., 2020). The visual feedback provided by the device motivates patients to engage actively in their respiratory care, ultimately supporting better recovery outcomes and reducing the length of hospital stays (Harris et al., 2018).

Actual patient response: "I can feel my chest opening up more when I take those deep breaths with the spirometer. I’ve been able to cough up some mucus that was stuck in my chest, and I feel like I can breathe easier now."

Evaluation: noted significant improvement in my patient's respiratory status. he reports a feeling of increased chest expansion and a notable reduction in breathlessness, Oxygen saturation levels have improved to 95%, and auscultation reveals clearer lung sounds. he successfully coughed up thick mucus, indicating better airway clearance. Overall, the incentive spirometer has positively impacted the patient's ability to manage secretions and enhance respiratory function, contributing to a greater sense of well-being and comfort.

4.nursing intervention: Collaborate with a respiratory therapist to implement chest physiotherapy techniques, such as percussion and postural drainage, to help mobilize secretions

Scientific rationale: Chest physiotherapy (CPT) is a therapeutic intervention designed to improve airway clearance in patients with conditions characterized by increased secretions and inflammation, such as pulmonary infiltrates. The scientific rationale for CPT lies in its ability to enhance mucus clearance through techniques such as percussion, vibration, and postural drainage, which help mobilize secretions from the peripheral airways to the central airways, where they can be more easily expectorated (Bourbeau et al., 2018). Studies have shown that CPT can lead to improved lung function, reduced work of breathing, and decreased respiratory distress by promoting effective airway clearance and preventing complications such as atelectasis and respiratory infections (Fitzgerald et al., 2017). Additionally, the application of mechanical oscillation during CPT has been demonstrated to improve the viscoelastic properties of mucus, thereby facilitating its clearance (Khan et al., 2020)

Actual patient response: "It was uncomfortable at first, but after the therapy, I noticed I was able to take deeper breaths without feeling as congested."

Evaluation: After chest physiotherapy, the patient shows significant improvement in respiratory function and comfort. his respiratory rate has stabilized within normal limits (19), and oxygen saturation has increased to 95%, indicating better oxygenation. Auscultation reveals clearer lung sounds with reduced wheezing and crackles, suggesting effective clearance of secretions. He reports a productive cough, successfully expelled approximately 15 mL of thick, yellow mucus during the session and expresses relief, Additionally, he demonstrated improved activity tolerance, able to engage in light activities without experiencing shortness of breath.

5.nursing intervention: Encourage adequate fluid intake

Scientific rationale: This helps to thin mucus and promote easier expectoration. Hydration plays a significant role in maintaining the optimal viscosity of respiratory secretions; adequate fluid intake can reduce the thickness of mucus, making it easier to mobilize and clear from the airways (Bourbeau et al., 2018). Studies indicate that increased hydration can enhance mucociliary function, thereby improving the clearance of secretions and reducing the risk of respiratory complications such as infections and atelectasis (Morris et al., 2020). Moreover, hydration contributes to overall respiratory health by maintaining adequate airway moisture, which is essential for effective ciliary function and mucus transport (Hahn et al., 2019).

Actual patient response: "I’ve been drinking more water, and I can feel it’s helping; I also notice that my throat feels less scratchy, and it’s easier to breathe."

Evaluation: the focus on increasing fluid intake has positively impacted the patient's ability to manage secretions and has contributed to improved respiratory function, The patient reports feeling less congested and is successfully able to expectorate thicker mucus, indicating better airway clearance

6. nursing intervention: Perform oral or nasal suctioning as needed to clear excessive secretions while using sterile technique to minimize infection risk.

Scientific rationale: this practice is grounded in its ability to directly remove obstructive secretions from the airways, thereby improving ventilation and oxygenation (Rumbak et al., 2020). Suctioning aids in maintaining airway patency by clearing thick mucus that can accumulate in the upper and lower airways, which is especially important in patients with conditions such as pneumonia or chronic obstructive pulmonary disease (COPD) (Bourbeau et al., 2018). Studies have shown that effective suctioning can lead to improved respiratory function, reduced work of breathing, and decreased risk of complications such as atelectasis and infection (López et al., 2019). Furthermore, the use of sterile technique during suctioning minimizes the risk of introducing pathogens into the respiratory tract, thus safeguarding the patient's respiratory health (Hahn et al., 2020).

Actual patient response: "Wow, that’s such a relief! I can finally take a deep breath, It feels so much clearer now." The patient also mentions feeling less anxious, saying, "I was really worried about not being able to breathe well, but now I feel like I can talk and move around without struggling." Overall, the patient appears more relaxed and comfortable, clearly appreciating the immediate effects of the suctioning.

Evaluation: after treatment the patient reports immediate relief indicating enhanced airflow. Upon assessment, lung auscultation shows marked reduction in wheezing and crackles, with clearer breath sounds noted, particularly in the lower lobes. The patient was able to expectorate approximately 30 mL of thick, yellow mucus during the procedure, suggesting effective removal of secretions. Oxygen saturation levels improved to 97%, up from 95% prior to suctioning. The patient exhibits a more relaxed demeanor, with decreased anxiety about breathing difficulties.

7.nursing intervention: Position the patient in a high Fowler’s position to facilitate breathing and promote lung expansion

Scientific rationale: its ability to facilitate lung expansion and improve ventilation. By elevating the head of the bed to an angle of 60 to 90 degrees, gravity assists in reducing the work of breathing and promoting optimal lung perfusion (Bourbeau et al., 2018). High Fowler’s position also enhances diaphragmatic movement and increases tidal volume, which can help mobilize secretions from the peripheral airways to the central airways, making them easier to expectorate (Huang et al., 2020). Furthermore, this position can alleviate pressure on the diaphragm from abdominal organs, allowing for more effective breathing mechanics (Nishida et al., 2019)

Actual patient response: After being positioned in high Fowler's position, he smiles and says, "Wow, I can breathe so much better now!" he took a deep breath and add, "It really feels like my chest has more room. I don’t feel as tight anymore”.

Evaluation: the evaluation demonstrates clear benefits for their respiratory condition. his respiratory rate decreased to a more normal range of 18 breaths per minute, and using fewer accessory muscles, suggesting that he is breathing more efficiently.

8. nursing intervention: Administer prescribed bronchodilators (Ipratropium bromide 0.5/2.5 inhalation) as needed to open airways and improve airflow, monitoring for therapeutic effects.

Scientific rationale: this treatment is based on the drug's anticholinergic properties, which lead to the relaxation of bronchial smooth muscles, thereby widening the airways and facilitating improved airflow (Harris et al., 2020). By reducing bronchoconstriction, Ipratropium bromide helps alleviate symptoms of wheezing and shortness of breath, allowing for more effective coughing and mucus clearance (Bourbeau et al., 2018). Additionally, studies have shown that bronchodilator therapy can enhance mucociliary clearance by improving the mobility of cilia and the viscosity of secretions, which further supports the management of airway clearance in patients with conditions such as COPD and asthma (Morris et al., 2019).

Actual patient response: After receiving the Ipratropium bromide inhalation The patient looks visibly more relaxed and adds, "I was really struggling before, but now I feel like I can actually take a full breath."

Evaluation: After administering the prescribed bronchodilator, Ipratropium bromide 0.5/2.5 inhalation, the evaluation indicates significant improvement in his respiratory parameters. Oxygen saturation levels increased from 90% to 95%, reflecting enhanced gas exchange and oxygenation. His respiratory rate decreased from 24 breaths per minute to 20, indicating a more stable and efficient breathing pattern. Additionally, he demonstrated an increased ability to engage in conversation without displaying signs of shortness of breath, and the use of accessory muscles during breathing was notably reduced. These changes suggest that the bronchodilator effectively facilitated airway relaxation and improved overall respiratory function.

9.nursing intervention: Monitor Sputum Production

Scientific rationale: the rationale for this practice lies in its role in assessing the patient's respiratory status and the effectiveness of treatment interventions. Changes in the quantity, color, and consistency of sputum can provide valuable insights into the progression or resolution of respiratory conditions such as pneumonia, bronchitis, or chronic obstructive pulmonary disease (COPD) (Nicolini et al., 2020). For instance, an increase in sputum volume or a change to purulent or discolored sputum may indicate an exacerbation of infection or inflammation, necessitating adjustments in therapy (Bourbeau et al., 2018). Additionally, monitoring sputum can guide clinicians in evaluating the effectiveness of airway clearance techniques and medications, helping to determine if the patient's airway management plan needs modification (Hahn et al., 2019).

Actual patient response: "I’ve noticed I’m coughing up more mucus than before, and it feels a bit looser." They take a moment to think and add, "It’s still thick, but I can tell it’s getting easier to bring up. I didn’t expect to see this much change so quickly." The patient also mentions, "I think the extra fluids I’ve been drinking are helping, too."

Evaluation: Upon monitoring sputum production, the evaluation reveals a notable increase in the quantity and quality of secretions. The patient is producing approximately 30 mL of sputum per day, which has changed from thick and yellow to a slightly thinner consistency, indicating an improvement in airway clearance. The patient's effort to stay hydrated appears to be effective, as they report feeling less congested and are able to expectorate more easily. Additionally, the frequency of coughing has decreased, suggesting improved ventilation. Overall, the monitoring of sputum production shows positive progress in managing increased secretions and inflammation

10. nursing intervention: Use of Humidified Oxygen

Scientific rationale: this practice is based on the role of humidity in maintaining airway moisture and enhancing mucociliary function. Humidified oxygen helps to prevent airway dryness, which can thicken secretions and impair mucociliary clearance, thereby exacerbating airway obstruction (Rubenfeld et al., 2018). Studies have shown that delivering oxygen with adequate humidity can significantly improve secretion viscosity, making it easier for patients to expectorate mucus and clear their airways effectively (Bourbeau et al., 2019). Furthermore, maintaining adequate humidity levels in the airways contributes to overall respiratory comfort and can help reduce coughing and irritation associated with dry air (Sinha et al., 2020).

Actual patient response: "I was feeling so tight and dry before, but now it’s like I can finally breathe without that scratchy feeling." The patient looks visibly more relaxed and remarks, "It’s much easier to talk, and I don’t feel as winded. I didn’t realize how much a little humidity could help."

Evaluation: After administering humidified oxygen to the patient, The patient’s oxygen saturation levels rose from 90% to 94%, reflecting enhanced gas exchange. he reported a notable decrease in airway dryness and irritation, stating that their throat feels less scratchy and they can breathe more comfortably. Additionally, the patient was able to cough more effectively, producing about 20 mL of thinner, less viscous sputum, which suggests improved airway clearance. Their respiratory rate stabilized at 20 breaths per minute, down from 23, indicating a more relaxed breathing pattern

11.nursing intervention: Provide education on the importance of airway clearance techniques and the role of hydration in managing secretions

Scientific rationale: The scientific rationale for this educational intervention is rooted in the understanding that effective airway clearance techniques, such as deep breathing, coughing, and postural drainage, enhance the mobilization and expectoration of mucus, thereby improving overall respiratory function (Nicolini et al., 2020). Education empowers patients to actively participate in their care, leading to better adherence to techniques that can prevent complications like atelectasis and respiratory infections (Bourbeau et al., 2018).

Actual patient response: patient appear empowered by the education and eager to apply what he learned to improve his respiratory health

Evaluation: Following the education on airway clearance techniques, the evaluation reveals that the patient has gained a solid understanding of his significance in managing secretions. he correctly articulated the purpose of techniques such as deep breathing, coughing, and using incentive spirometer. he demonstrated the ability to describe the steps involved in these techniques and expressed motivation to incorporate them into his daily routine, saying, "I’m going to practice these exercises every day." Additionally, he asked relevant questions about when and how often to perform these techniques, indicating his engagement and commitment to improving his respiratory health. Overall, the education provided has effectively empowered the patient to take proactive steps in managing his condition.

12.nursing intervention: Provide Oral Care

Scientific rationale: this intervention is primarily focused on maintaining oral hygiene, which can significantly impact respiratory health. Poor oral hygiene can lead to the colonization of pathogenic bacteria in the mouth, which may subsequently be aspirated into the lungs, increasing the risk of respiratory infections such as pneumonia (Ryu et al., 2019).

Additionally, regular oral care helps to remove thickened secretions from the oral cavity, which can improve the patient’s ability to cough effectively and clear mucus from the airways (McClish et al., 2020). Studies have shown that patients who receive consistent oral care exhibit better overall respiratory function, as oral hygiene can enhance mucociliary clearance by reducing the microbial load in the upper respiratory tract (Hahn et al., 2020). Therefore, educating patients and caregivers about the importance of oral care is essential for enhancing airway clearance and preventing complications associated with increased secretions and inflammation.

Actual patient response: "That was really refreshing! My mouth feels so much cleaner, and I don’t have that nasty taste anymore."

Evaluation: The patient reported feeling much more comfortable, stating that his mouth was cleaner and no longer felt dry. Objective findings showed a noticeable reduction in oral secretions, with him able to expectorate thicker mucus more easily following the oral care. Additionally, his speech was clearer, and he expressed greater ease in swallowing. This indicates that the oral care not only improved his oral hygiene but also contributed positively to managing airway clearance.

Overall Evaluation of Goal attainment and care effectiveness:

Describe the relationship between the nursing diagnosis/problem (ineffective airway clearance related to increased secretions and inflammations and inflammation second to pulmonary infiltrate) in this plan and the other two nursing diagnosis/problem you identified on the Clinical Worksheet ( ineffective peripheral tissue perfusion related to interruption of venous blood flow second to DVT) and (powerlessness related to lack of control over health condition and treatment outcomes)