- ( )Actual
- ( )Potential
Related To :
- Atrificial airway
- Excessive or thick secretions
- Inability to cough effectively
- Infection
- Obstruction/restriction
- Pain
- Other
As evidenced by :
Major:
- Ineffective cough.
- Inability to remove airway secretions.
- Abnormal breath sounds.
- Abnormal respiratory rate, rythm, depth.
Plan and Outcome
The patient will:
- Maintain patent airway A.E.B.:
- Clear breath sounds or breath sounds consistent with own baseline.
- Respirations easy and un-labored.
- Normal resp. rate.
- Other:
Nursing Interventions
- Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.
- Position: HOB elevated ___ degrees.
- Promote optimum level of activity for best possible lung expansion :
- Ambulate q ___ for ___ min.
- Chair q ___ for ___ min.
- Turn/reposition q ___.
- Suction q ___ hours (and prn) per:
- Nasal
- Oral
- Tracheal
- Encourage fluids when indicated.
- Other:________________
Patient/Significant other signature
__________________________
RN signature