NAME: DIZON, DEXIE

F  Ineffective Airway Clearance r/t excessive secretions and ineffective coughing

D  Received patient sitting on bed with fremitus, profuse sweating and shivering
 With productive cough accompanied by blood-tinged sputum
 With crackles heard on the upper right lung field.

A  Assessed respirations. Noted quality, rate, pattern, depth, flaring of nostrils, dyspnea on
exertion, evidence of splinting, use of accessory muscles, and position for breathing
 Assessed hydration status: skin turgor, mucous membranes, tongue
 Performed nasotracheal suctioning as necessary, especially when cough is ineffective.
 Checked for peak airway pressures and airway resistance, if patient is on mechanical
ventilation
 Provided postural drainage, percussion, and vibration as ordered
 Positioned the patient upright if tolerated. Regularly check the patient’s position to
prevent sliding down in bed
 Administered medications as prescribed, such as antibiotics, mucolytic agents,
bronchodilators, expectorants, noting effectiveness and side effects
 Encouraged patient to increase fluid intake to 3 liters per day within the limits of
cardiac reserve and renal function
 Taught patient with coughing, deep breathing, and splinting techniques
 Educated patient of the following:●Optimal positioning (sitting position)●Use of
pillow or hand splints when coughing ●Use of abdominal muscles for more forceful
cough ●Use of quad and huff techniques ●Use of incentive spirometry ●Importance of
ambulation and frequent position changes

R  Receptive to health teachings and demonstrated ability to classify methods to enhance

secretion removal and identify factors that inhibit effective airway clearance.

SECTION: MIXED GROUP

ROTATION: December 14-16 2020