1.

Airway Obstruction
Therapeutic Interventions
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Assist patient in performing coughing and breathing maneuvers.
To improve productivity of the cough.
(i) Instruct patient in 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.

o These methods help maintain adequate lung expansion thus
preventing buildup of secretions and atelectasis.

(i) Use positioning

(if tolerated, head of bed at 45 degrees; sitting in chair, ambulation).
To facilitate clearing of secretions
These promote better lung expansion and improved air exchange.
(i) If bedridden, routinely check the patient's position so he or she does
not slide down in bed.
This may cause the abdomen to compress the diaphragm, which would
cause respiratory embarrassment.
(c) If cough is ineffective, use nasotracheal suctioning as needed
To remove sputum and mucous plugs.

Explain procedure to patient.

Use soft rubber catheters

o To prevent trauma to mucous membranes.

Use curved-tip catheters and head positioning (if not contraindicated)

o To facilitate secretion removal from a specific side (right versus left
lung).

Instruct the patient to take several deep breaths before and after each
nasotracheal suctioning procedure and use supplemental O2 as
appropriate
o To prevent suction-related hypoxia.

Stop suctioning and provide supplemental O2 (assisted breaths by ambu

bag as needed) if the patient experiences bradycardia, an increase in
ventricular ectopy, and/or desaturation.

Use universal precautions: gloves, goggles, and mask as appropriate.

o If sputum is purulent, precautions should be instituted before
receiving the culture and sensitivity report.

(c) Institute appropriate isolation precautions for positive cultures

(e.g., methicillin-resistant Staphylococcus aureus[MRSA], tuberculosis,
and others).
(i) Use humidity (humidified O2 or humidifier at bedside).
To loosen secretions
(i) Encourage oral intake of fluids within the limits of cardiac reserve
To prevent drying of secretions.
(c) Administer medications (e.g., antibiotics, mucolytic agents,
bronchodilators, expectorants) as ordered, noting effectiveness and
side effects.
(c) For patients with chronic problems with bronchoconstriction,
instruct in use of meter dose inhaler (MDI) or nebulizer as prescribed.
(c) Consult respiratory therapist for chest physiotherapy and nebulizer
treatments as indicated (hospital and home care/rehabilitation
environments). Coordinate optimal time for postural drainage and
percussion, that is, at least 1 hour after eating
To prevent aspiration.
(i) For patients with reduced energy, pace activities.
Maintain planned rest periods. Promote energy conservation
techniques.
To prevent fatigue.
(c) For acute problem, assist with bronchoscopy

To obtain lavage samples for culture and sensitivity, and to remove

mucous plugs.
(c) If secretions cannot be cleared, anticipate the need for an artificial
airway (intubation). After intubation:

Institute suctioning of airway as determined by presence of adventitious

sounds.

Use sterile saline instillations during suctioning

o To help facilitate removal of tenacious sputum.

(c) For patients with complete airway obstruction, institute

cardiopulmonary resuscitation (CPR) maneuvers.

2. Aspiration
Therapeutic Interventions
Actions/Interventions/Rationale
Key:

(i) independent
(c) collaborative
(i) Keep suction setup available (in both hospital and home setting) and
use as needed
To maintain a patent airway.
(i) Notify the physician or other health care provider immediately of
noted decrease in cough and/or gag reflexes, or difficulty in
swallowing.
Early intervention protects the patient's airways and prevents aspiration.
(i) Position patients who have a decreased level of consciousness on
their side.
To protect the airway. Proper positioning can decrease the risk of
aspiration. Comatose patients need frequent turning to facilitate drainage
of secretions.
(i) Supervise or assist patient with oral intake
Never give oral fluids to a comatose patient.
To detect abnormalities early.

(i) Offer foods with consistency that patient can swallow.

Use thickening agents as appropriate. Cut foods into small pieces.
Semisolid foods like pudding and hot cereal are most easily swallowed.
Liquids and thin foods like creamed soups are most difficult for patients
with dysphagia.
(i) Encourage patient to chew thoroughly and eat slowly during meals.
Instruct patient not to talk while eating.
(i) For patients with reduced cognitive abilities, remove distracting
stimuli during mealtimes.
To facilitate concentration chewing and swallowing.
(i) Place whole or crushed pills in soft foods (e.g., custard). Verify with
a pharmacist which pills should not be crushed. Substitute medication
in elixir form as indicated.
(i) Position patient at 90-degree angle, whether in bed or in a chair or
wheelchair. Use cushions or pillows to maintain position.
Proper positioning of patients with swallowing difficulties is of primary
importance during feeding or eating.
(i) Maintain upright position for 30 to 45 minutes after feeding.
The upright position facilitates the gravitational flow of food or fluid
through the alimentary tract. If the head of bed cannot be elevated
because of patient's condition, use a right side-lying position after
feedings to facilitate passage of stomach contents into the duodenum.
(i) Provide oral care after meals.
To remove residuals and to reduce pocketing of food that can be later
aspirated.
(c) In patients with nasogastric (NG) or gastrostomy tubes:

Check placement before feeding.

o A displaced tube may erroneously deliver tube feeding into the
airway.

Check residuals before feeding. Hold feedings if residuals are high and
notify the physician.
o High amounts of residual (greater than 50% of previous hour's
intake) indicates delayed gastric emptying and can cause distention
of the stomach leading to reflux emesis.

Place dye (e.g., methylene blue) in NG feedings.

o Detection of the color in pulmonary secretions would indicate
aspiration.

Position with head of bed elevated 30 to 45 degrees.

(c) Use speech pathology consultation as appropriate.

A speech pathologist can be consulted to perform a dysphagia
assessment that helps determine the need for video fluoroscopy or
barium cookie swallow.

laryngospasm and
bronchospasm
3.
1.

Adequately hydrate the pt.

-systemic hydration keeps secretion moist and easier to expectorate.

2. Teach and encourage the use of diaphragmatic breathing and coughing
exercises
- These techniques help to improve ventilation and mobilize secretions w/o
causing breathless and fatigue
3. Instruct pt. to avoid bronchial irritants such as cigarette smoke, aerosol,
extremes of temp. , and fumes
- bronchial irritants cause bronchoconstriction and increased mucus
production, w/c then interfere w/ airway clearance.

D. HYPOXEMIA
1. Identifying the etiology / factor triggers
Rational: understanding the causes of lung collapse necessary for the proper installation of
the chest tube and choose another teraupetik action.
2. Evaluation of respiratory function.
Rational: respiratory distress and changes in vital signs may occur due to physiological
stress and may indicate the occurrence of pain or shock.
3. Auscultation of breath sounds
Rational: The sound of the breath can be decreased or no lobe, lung segment or the entire
lung.
4. Assess fremitus
Rational: Sound and tactile fremitus (vibration) decreases in fluid-filled tissue /
consolidation.
5. Collaboration in the assessment of radiographic series
Rational: hemathorak improvement and monitor progress of lung expansion.
6. Collaboration in the provision of supplemental oxygen through a cannula / mask as
indicated.
Rational: A tool in reducing the work of breath, increased respiratory distress and cyanosis
relief with respect to hypoxemia.

E.

PULMONARY EMBOLISM

1.Frequently assess respiratory statusincluding rate, depth, effort, lung

soundand SPO2
.- Impaired ventilation affects gas exchangeand worsens
hypoxemia(Tachypnea,dyspnea). SPO2 can be used as a non-invasive
method to monitors oxygensaturation
.2. Assess the mental status of the client(changes in orientation and
behavior)
-Restlessness is an early sign of hypoxia.Hypoxemia often causes
confusion andagitation
.3. Monitor ABGs and note changes
- ABGs used to assess gas exchange of client
4.Position the patient in high fowlers position
-To facilitate maximal lung expansion/improve ventilation and reduce
venous return to the right side of the heart
.5.Administered oxygen as ordered by doctor -To improve oxygenation.Maintain bed rest
-Bed rest reduces metabolic demands for oxygen
6.Administer medications(anticoagulants) as prescribed bydoctor. E.g lowmolecular-weight, heparin, warfarin etc
- Anticoagulant therapy is preventive by inhibiting further clot
formation.

Nursing Interventions for Pneumonia

Intervention and Rationale:
I. Assess for:

Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of
accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data
baseline.
Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
Quality of cough and ability to raise secretions including consistency and characteristics od
sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and
consolidation of lungs; clearing airways facilitates breathing.
II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of
disease.
ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.
III. Administer:

Oxygen therapy via cannula - maintain optimal oxygen level.

Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid
production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve
non-productive cough
Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.

Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and
destroying pathogens.
IV. Perform or Provide:

Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and
allows for full expansion of lungs.

Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer
cough suppresant - reduces continual irritation to throat and liquefies secretions.

Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and
prolongs expiratory phase.

Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and
improves ventilation, moistens mucous membranes

Postural drainage and percussion PRN - mobilizes secretion.

Suction secretions if cough ineffective - removal if unable to bring up secretions.

Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and
prevents transmission of organisms to others.

F. ATELECTASIS

Encourage the patient to perform coughing and deep-breathing exercises every 1

to 2 hours.
2.
Help the patient use an incentive spirometer to encourage deep breathing.
3.
Gently reposition the patient often and help him walk as soon as possible.
4.
Administer adequate analgesics to control pain.
5.
Humidify inspired air and encourage adequate fluid intake to mobilizesecretions.
6.
Use postural drainage and chest percussion to remove secretions.
7.
Provide suctioning as needed for patients who are intubated or unable to clear
their own secretions.
8.
Administer sedatives with care because these medications depress respirations
and cough reflex.
9.
Offer ample reassurance and emotional support because the patients limited
breathing capacity may frighten him.
10.
Assess breath sounds and respiratory status frequently. Report any changes
immediately.
11.
Evaluate the patients ability to perform bronchial hygiene.
12.
Monitor pulse oximetry readings and ABG values for evidence of hypoxia.
13.
Demonstrate comfort measures to promote relaxation and conserve energy.
1.

G. PULMONRY EDEMA

1.
2.
3.

Help the patient relax to promote oxygenation.

Place the patient in high Fowlers position to enhance lung expansion.
Administer oxygen as ordered.

4.
5.
6.
7.
8.

Carefully record the time morphine is given and the amount administered.
Assess the patients condition frequently.
Watch for complications of treatment such as electrolyte depletion.
Monitor vital signs every 15 to 30 minutes or more often as indicated.
Urge the patient to comply with the prescribed medication regimen to avoid
future episodes of pulmonary edema.
9.
Explain all procedure to the patient and his family.
10.
Emphasize reporting early signs of fluid overload.
11.
Review all prescribed medications with the patient.
12.
Discuss ways to observe physical energy.