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Ineffective Airway Clearance related to Tonlilitis

Nursing Diagnosis : Ineffective Airway Clearance related to Tonlilitis

Ineffective airway clearance related to presence of foreign bodies, excess production secret.

Characteristics:
  • Dyspnea
  • Orthopnea
  • Difficulty speaking
  • Changes in rhythm and respiratory frequency
  • Anxiety
  • Additional breath sounds
  • Cyanosis
  • Decreased breath sounds
  • Ineffective cough
  • The production of secret / sputum
Goal:
  • Dyspnoea, orthopnea, cyanosis does not exist
  • The rhythm and the respiratory frequency, within normal limits
  • Not nervous
  • No additional breath sounds.

Ineffective Airway Clearance related to Tonlilitis

  1. Assess / monitor respiratory frequency
  2. Auscultation of breath sounds, record the sound of breath
  3. Note the presence of dyspnea, restlessness, anxiety, respiratory distress, use of auxiliary respiratory muscles.
  4. Assess the patient to a comfortable position, eg: Elevation head of the bed, sitting on the back of the bed.
  5. Do it with a regular oral hygiene.
  6. If need to do suctioning
  7. Oxygenation
  8. Tachypnea can be found at the reception or during the acute infection process.
  9. Airway obstruction may / not manifested adventisius of breath sounds.
  10. Respiratory dysfunction is a variable that depends on the stage of a chronic process than the process leading to acute hospital care.
  11. Bed elevation facilitate respiratory function using gravity
  12. Oral hygiene can prevent the infection persists and can control the spending secret.
  13. help the secret spending on patients who are unable to issue a secret self through an effective form.
  14. Oxygen delivery to help clients meet the need of oxygen that may not be properly fulfilled due to airway obstruction.

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