INTERVENTIONS: Assessed respiratory rate.

Noted chest movement; use of accessory muscles during respiration.

Auscultated breath sounds; noted areas with presence of adventitious sounds. Documented respiratory secretions: character and amount of sputum. Maintained patient on moderate high back rest.

Checked for obstructions: accumulation of secretions. Suctioned patient limited to 5-sec duration.

RATIONALES:
Provides a basis for evaluating adequacy of ventilation. Use of accessory muscles of respiration may occur in response to ineffective ventilation. Crackles indicate accumulation of secretions and inability to clear airways. Expectorations may be different when secretions are very thick.

Positioning helps maximize lung expansion.

To maintain adequate airway patency. Duration should be limited to reduce hazard of hypoxia, damage airway mucosa and impair cilia action.

Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.