Nursing Care Plan for Airway Purification (Adult)

<Definition>
Ineffective airway cleansing is a condition in which secretions from the bronchial glands increase due to decreased hair movement and cough reflex, and the secretions or obstructions cannot be effectively removed.

<Nursing care plan>
Target
Airway secretions are removed and you can breathe comfortably
Airway secretions are removed and no respiratory complications occur
You can sputum yourself
You can handle it yourself when it is difficult to sputum

Observation plan
1. Presence or absence of respiratory disease
2. Disease, treatment content
3. Resident history
4. Presence or absence of allergies
5. Smoking or non-smoking, smoking amount (current / past)
6. Test data (chest X-ray, blood gas (PaO2, PaCO2, SaO2, pH, HCO3-, BE), CRP, WBC, sputum bacterial test)
7. Consciousness level
8.ADL, presence or absence of paralysis
9. Swallowing status, presence or absence of swelling
10. Fever type, presence or absence of respiratory infection signs
11. Breathing status (breathing rate, SpO2, difficulty breathing, lung sound and laterality, lung noise, pant, cough, abnormal breathing, chest movement)
12. Presence or absence of symptoms due to hypoxemia
-Blood pressure and pulse fluctuations
-Cyanosis, cold limbs, deterioration of complexion
-Bad mood
-Frustrated
-Not lively
13. Presence / absence, properties, amount of secretions
14. Presence / absence and degree of cough
15. Sputum sputum output status
16. Presence / absence of suction, interval, frequency, site of implementation (oral cavity, nasal cavity, tracheostomy, ventilator)
17. Presence / absence, method and amount of oxygen administration
-Nasal cannula
-Face mask
-Inspiron mask
-Ventilator
18. Humidification status
19. Whether or not to use a ventilator, settings and measured values
20. Dietary intake
21. Sleep status
22. Mental state
23. Status of response to difficulty in sputum production

Care plan
1. Change body position as needed (  ,  ,  ,  )
2. Perform postural drainage
-Right side(  ,  ,  ,  )
-Left side(  ,  ,  ,  )
-Fowler’s position, supine position (  ,  ,  ,  )
-Sims position (  ,  ,  ,  )
-Prone position (  ,  ,  ,  hour)
3. If the oral cavity is dry, moisten the oral cavity with gauze etc.
4. Aspirate secretions when sputum is difficult
5. Implement an ultrasonic neplyzer
-Chemical solution (), spray amount (), time () minutes
6. Give oxygen therapy as directed by your doctor
7. Humidify as needed
8. Manage the ventilator
9. Patients wearing a ventilator should bed up about 30 degrees to prevent VAP.
10. Take measures to prevent aspiration (position, diet, intake from healthy side, etc.)
11. Perform relaxation such as massage and stretching
12. Provide mental assistance (such as calling out frequently)

Education plan
1. Explain the need for repositioning (promoting removal of secretions, prevention of pulmonary complications, etc.)
2. Explain care and practices for removing secretions
-Position change
-Ultrasonic nebulizer
-Suction
3. If you have difficulty swallowing, explain how to devise a diet, how to eat, how to drink, and how to swallow.
4. If you are a smoker, give guidance on smoking cessation
5. Explain how to self-sputum and how to devise
-Gargling firmly
-Drink more water
-Humidify the room
-Perform a nebulizer
-Perform postural drainage
-A method of breathing that promotes the removal of secretions
-How to cough to help remove secretions

Suction procedure ・ One point
-Explain the need for suction to the patient
-When listening to abnormal breath sounds in the periphery, incorporate postural drainage and respiratory rehabilitation, move the secretions to the tracheal bifurcation, and then perform suction.
-Do not inhale for more than 10 seconds to prevent hypoxia, alveolar prolapse, and damage to the airway mucosa
-If inhalation lowers SPO2 and does not restore respiratory status, report to your doctor immediately and respond as directed.

One point of management during intubation
-Make sure to fix the intubation tube
-Suction is done while fixing the tube to reduce irritation
-Be careful of hypoxia before and after suction, and pressurize with Jackson Reese or bag balp mask when necessary.
-If the sputum is viscous, use an ultrasonic nebulizer, etc., and then perform suction.


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