8/4/2019 Airway Clearance and Hyperthermia
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Assessment Explanation of theProblem
Goals and Objectives Nursing Intervention Rationale
Evaluation
S> May ubo siya atmay ksamang
plema asverbalized by his
mother
O > RR 38> Nasal flaring
noted> breathes through
mouth> stridor noted
> with good suck
A> ineffective
airway clearancerelated to presence
of secretions at thetracheo bronchial
tree
Irritants enter the URT
Causes Irritation to the
nasal mucosa
Stimulates moderate to
excessive mucusproduction
Cough as if not ableA defense to expecto
Mechanism rateTo remove mucus
Irrirtants
Blocks airways
Amt of air that enters is
decreasedBreathes
through mouthNasal flaring
Difficulty of breathing
STO: After 3 hours of nsg.
Intervention the patientwill demonstrate
behaviors to improve ormaintain clear airway
: After 3 hours of nsg.
Intervention the patientwill be able to
expectorate secretionsreadily
LTO
: After 3 days of nsg.Intervention the patient
will demonstrateabsence/reduction of
congestion with clearbreath sounds, noiseless
respiration an improvedoxygen exchange
Dx
periodic
assessment of rate,depth & effort of
respiration
Assess Temp andpulse periodically
Auscultate lung
fields
Tx
Position head
midline w/ flexionapprop. For age
frequent position
changes
gives indications as
to extent of resp.difficulty or relief the
client will experience
Serves as a baselinedata because inc. in
v/s reflect increasingdiff. in respiration
To determine areas of
decreased airflow inthe lower resp.
system, which mayaggravate diff. of
breathing andcoughing
to maintain openairway in at-rest
mobilizes secretionsfor easier
expectoration
>Goal met if After 3 hoursof nsg. Intervention the
patient will demonstratebehaviors to improve or
maintain clear airway
> Goal met if After 3 hours
of nsg. Intervention thepatient will be able to
expectorate secretionsreadily
>Goal met if After 3 daysof nsg. Intervention the
patient will demonstrateabsence/reduction of
congestion with clearbreath sounds, noiseless
respiration an improvedoxygen exchange
8/4/2019 Airway Clearance and Hyperthermia
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Assessment Explanation of the
Problem
Goals and Objectives Nursing Intervention Rationale
Evaluation
S> Mejo mainit ang
aking pakiramdam
O
febrile T > 38.5
warm to touch
flushed skin
dry oral mucosa
A> Altered
thermoregulatory status:hyperthermia related to
ongoing infectiousprocess
Bacteria enters the
respiratory tract
Lodges in the lungs
Proliferation of bacteriain the cells
Release of bacterialendotoxins
reachesHypothalamus
Altered thermoregulatorystatus
Hyperthermia
STO
: after 2 hours of nursing
intervention the patientstemperature will dropfrom 38.5 to
37.5
LTO
: after 3 days of nursingintervention the patient
will be able todemonstrate behaviors to
monitor and promote
normothermia
Dx
Monitor
respirations
Note
presence/absenceof sweating as
body attempts toinc. heat loss by
evaporation,conduction and
diffusionTx
Maintain bed rest
Provide highcalorie diet
Ensure safety
Administer medsas ordered
hyperventilation
may initially be
present
Evaporation isdec. by envt
factors of highhumidity and
high ambientTemp.
to reducemetabolic
demands/ O2consumption
to meet inc.metabolic
demands
to prevent injury
to treatunderlying cause
> Goal met if after 2
hours of nursing
intervention the patientstemperature will dropfrom 38.5 to
37.5
> Goal met if after 3
days of nursingintervention the patient
will be able todemonstrate behaviors to
monitor and promote
normothermia
