Priority Nursing Diagnosis R/T:
Ineffective airway clearance related to secretion obstruction as evidenced by difficulty breathing and excessive
coughing.
Desired Patient Outcomes Nursing Interventions
1. Throughout the shift, patient will demonstrate 1. Patient was suctioned as needed and the head of the
an effective breathing (between safe range 16 bed was maintained elevated at 45 degree angle, no
to 20) with a patent airway by absence of less than 30 as patient tolerated.
expiratory wheezes and crackles, which
decrease air hunger and anxiety.
2. Monitor patient oxygen saturation with pulse 2. Patient was connected to the tracheotomy collar at
oximeter before, during, and after suctioning, 28% and 5L of oxygen at the shift start. Then, was
and every 4 hours through the shift. Making increased to 98% track collar 10L oxygen before,
sure to maintain the oxygen level above 92% during and after suctioning. After the suctioning
procedure, patient was readjusted to 50% trach collar
and 10L oxygen
Patient remained at 90% of oxygen saturation after
suctioning, but stated feeling better and was breathing
softly.
3. Patient lung will be auscultated on every 2 3. Decreased or absent breath sounds may indicate the
hours notifying the presence of adventitious presence of a mucus lump or other airway obstruction;
lung’s sound or decreased ventilation in the wheezing may indicate partial airway obstruction or
airway. narrowing coarse crackles and/or rhonchi may indicate
the presence of secretions along larger airways.
Patient respiration was softer at the end of the shift
with diminished wheezes and patient appeared less
anxious.
Ineffective airway clearance related to secretion obstruction as evidenced by difficulty breathing and excessive
coughing.
Desired Patient Outcomes Nursing Interventions
1. Throughout the shift, patient will demonstrate 1. Patient was suctioned as needed and the head of the
an effective breathing (between safe range 16 bed was maintained elevated at 45 degree angle, no
to 20) with a patent airway by absence of less than 30 as patient tolerated.
expiratory wheezes and crackles, which
decrease air hunger and anxiety.
2. Monitor patient oxygen saturation with pulse 2. Patient was connected to the tracheotomy collar at
oximeter before, during, and after suctioning, 28% and 5L of oxygen at the shift start. Then, was
and every 4 hours through the shift. Making increased to 98% track collar 10L oxygen before,
sure to maintain the oxygen level above 92% during and after suctioning. After the suctioning
procedure, patient was readjusted to 50% trach collar
and 10L oxygen
Patient remained at 90% of oxygen saturation after
suctioning, but stated feeling better and was breathing
softly.
3. Patient lung will be auscultated on every 2 3. Decreased or absent breath sounds may indicate the
hours notifying the presence of adventitious presence of a mucus lump or other airway obstruction;
lung’s sound or decreased ventilation in the wheezing may indicate partial airway obstruction or
airway. narrowing coarse crackles and/or rhonchi may indicate
the presence of secretions along larger airways.
Patient respiration was softer at the end of the shift
with diminished wheezes and patient appeared less
anxious.
