The Ineffective Airway Clearance

Published Date: 02 Nov 2017

Maintaining skin integrity is vital. According to McCance and Huether (2006) the skin acts as a barrier and protects the body against micro organisms and ultraviolet radiation. It is very important to prevent the risk of developing pressure ulcers, skin tears and infections. (Department of Health, [DH], 2010) Mr Hay has developed a stage 1 pressure area to his right hip, ankle and shoulder. Pressure ulcers and skin tears can both be associated with pain, decreased mobility and an increased risk of in-hospital complications. (Department of Health, [DH], 2010)

The Department of Health (2010) encourages that skin should be kept intact and healthy which will protect the body and its organ function. Ageing can decrease skin integrity and its functions. The elderly skin can be more susceptible to damage and can be slower in the healing process. Any break or tear in the skin makes the body susceptible to infection. (Department of Health, [DH], 2010)

The goal for Mr Hay would be to heal his current pressure areas and to maintain skin integrity while preventing any more pressure ulcers from developing. (Lewis, Heitkemper, Dirksen, O’Brien, Bucher, 2008)

NURSING INTERVENTION

RATIONALES

EVALUATION

Use a risk assessment tool (Braden Scale) to monitor the individuals risk factors for pressure areas

(Lewis, et al. 2008)

Factors that contribute to development of pressure ulcers can be eliminated

(Lewis, et al. 2008)

The nurse identifies risk factors that can lead to a pressure area developing

Pressure Area Care – Reposition the patient every 1-2 hours and position them with pillows

(Lewis, et al. 2008)

This will help avoid prolonged pressure in one area and will elevate pressure points off the bed

(Lewis, et al. 2008)

Continue until patient is discharged because reducing pressure off pressure points will help the existing pressure ulcers to heal and prevent pressure sores from developing.

Describe and document any characteristics of the pressure ulcer Including pressure stage, size, colour, exudate, granulation and location of the pressure ulcer

(Lewis, et al. 2008)

This helps provide a baseline for the pressure ulcer and can help with monitoring changes that occur, such as advancing wound or infection

(Lewis, et al. 2008)

Documentation and monitoring of existing pressure ulcers will continue until pressure ulcers heal

Utilise specialty mattresses or sheep skin if required

(Lewis, et al. 2008)

Helps to provide pressure relief

Continue use of specialty mattress or sheep skin when ulcers heal if Mr Hay’s risk of pressure ulcers is high

Apply appropriate dressings to the pressure ulcer

(Lewis, et al. 2008)

To promote healing and protect Pressure ulcer

(Lewis, et al. 2008)

Mr Hay’s pressure ulcers will heal due to appropriate dressings

Clean pressure ulcer daily with normal saline using aseptic technique

(Lewis, et al. 2008)

Prevents infection and spread of micro organisms

Continue until pressure wounds are healed

Keep pressure wound moist

(Lewis, et al. 2008)

Helps with the healing process

Continue until pressure wound heals

Deride the ulcer if needed

(Lewis, et al. 2008)

This will help to promote new tissue growth

(Lewis, et al. 2008)

Mr Hay’s pressure ulcers will heal due to tissue growth

PROBLEM : INEFFECTIVE AIRWAY CLEARANCE

Mr Hay has an ineffective Airway clearance due to thick yellow sputum. He is also presenting with tachypnoea and shallow breathing. An ineffective airway clearance means that the body is disadvantaged from oxygen. ("eNotes", 2013) Mr Hay shows symptoms of shallow tachypnoea breathing. Tachypnoea means that the body is trying to release excess carbon dioxide. (Braun, Anderson, 2007) By trying to release this carbon dioxide the body increases the respiration rate. Tachypnoea can be an expected result to a fever, fear or even pneumonia. (Braun, Anderson, 2007)

It is very important that the airway is clear and effective because if gas exchange and ventilation isn’t re established then hypoxia and death to the vital organs can occur. ("eNotes", 2013) Ventilation includes the process of inspiration of oxygen and expiration which is removing carbon dioxide from the body. Transporting oxygen via the lungs is the only mechanism for obtaining oxygen. (Braun, Anderson, 2007) For cellular metabolism to take place, oxygen is vital. Oxygen is vital for the cell to expand energy efficiently and function correctly. The expiration of carbon dioxide is also very important. Releasing and retaining carbon dioxide helps maintain optimal cell function because it occurs within a narrow pH range. (Braun, Anderson, 2007)

To maintain an effective airway the goal is for Mr Hay to acquire oxygen which is needed for cell metabolism and remove Carbon Dioxide which is needed to maintain pH and optimal cell functioning. (Braun, Anderson, 2007) He is to demonstrate effective coughing and increased air exchange and for him to experience normal respiration rates. (Lewis, et al. 2008)

Nursing Intervention

Rationales

Evaluation

Administer Titrate Oxygen at 4L p.m via Hudson Mask as per Doctors request when required (increase if needed)

To keep O2 saturations >94%

Minimal flow rate will through mask prevents possibility CO2 accumulation and CO2 rebreathing

(The Royal Children’s Hospital, 2012)

Oxygen Saturations >94%

Respiratory rate decreases from 28bpm

Monitor Respirations hourly

Including respiration rate, depth and auscultation of breathing

To assess if the process of inspiration of oxygen and expiration of carbon dioxide is occurring

To assess that interventions are effective

(Braun, Anderson, 2007)

Respiratory rate <28bpm

O2 Saturations >94%

Monitor Pulse Oximetry hourly

Test that will measure oxygen saturation

Oxygen Saturation should be >94% as per Doctor

(Braun, Anderson, 2007)

O2 Saturations >94%

Encourage Mr Hay to slow deep breathe while also encouraging chest physio

(Lewis, et al. 2008)

Encourages gas exchange (inspiration of oxygen and expiration of carbon dioxide)

(Braun, Anderson, 2007)

Respiratory rate <28bpm

O2 Saturations >94%

Assist patient to remove secretions.

Encouraging coughing or suction if needed

(Lewis, et al. 2008)

Decreases thick mucus out of the airway making airway more clear

(Braun, Anderson, 2007)

Decrease in mucus allowing airway to be more clear

Auscultation of breath sounds and monitor any changes

(Lewis, et al. 2008)

To obtain data on patients response to interventions

(Lewis, et al. 2008)

Normal breath sounds with absence or decrease of wheezing / crackling sounds

Collect sputum sample in sterile container for pathology

Bacterial infection can be properly diagnosed and treatment can be given

(Lewis, et al. 2008)

Absence or decrease in thick yellow sputum

Provide Humidification of Oxygen if patient is requiring it for long periods of time

(Lewis, et al. 2008)

Promotes moisture to mucosa as normal oxygen can dry out mucosa and feel uncomfortable for the patient

Continue whenever Mr Hay requires oxygen for longer periods

PROBLEM - HYPERTHERMIA

Hyperthermia is an important problem statement in Mr Hay’s case because hyperthermia can cause nerve damage. Mr Hay’s temperature on admission was 38◦C and present vital signs show a temperature of 37.6◦C. Body temperature is usually maintained at 37◦C. Although different parts of the body show different temperatures a normal range in body temperature according to McCance and Huether (2006) is 36.2◦C – 37.7◦C. It’s important that Mr Hay’s temperature doesn’t exceed 37.7◦C . If temperature reaches 41◦Ccan result in nerve damage which can lead to convulsions. If temperature exceeds 43◦C it can result in death. (McCance, Huether, 2006)

McCance and Huether (2006) state that hyperthermia can either be accidental or therapeutic. Therapeutic hyperthermia means that the rise in temperature is encouraged by the body. The purpose of therapeutic hyperthermia is to destroy pathological micro organisms in the body. (McCance, Huether, 2006)

According to McCance and Huether (2006) the body’s temperature is regulated by the hypothalamus. This is transmitted by peripheral thermo receptors. The peripheral thermo receptors send information signals to the hypothalamus about the body’s temperature of the skin and core. If the body’s temperature is low then the hypothalamus will respond by increasing heat production which is distributed throughout the body by the circulatory system. (McCance, Huether, 2006)

If there is an infection then a fever is likely to be produced because an increase in body temperature will kill micro organisms. Instead of burning glucose the body will change to metabolise lipolysis and proteolysis, this will deprive the bacteria of any food sources. (McCance, Huether, 2006)

Nursing Intervention

Rationale

Evaluation

Monitor temperature with thermometer ( 2 Hourly )

(Carpenito-Moyet,2008)

Helps provide a baseline to monitor changes in temperature.

Temperature 36.2◦C – 37.7◦C

(Carpenito-Moyet,2008)

Monitor Mr Hay’s fluid intake and out put

Provide favourite fluids to increase his fluid intake

(Carpenito-Moyet,2008)

Decreases risk of dehydration

Fluids are required to maintain metabolic functions during a fever

(Carpenito-Moyet,2008)

Fluid Balance Chart showing that Input and output is balanced

Assess whether blankets or clothing are too much for room temperature or activity and remove excess clothing or blankets if needed to decrease heat

(Carpenito-Moyet,2008)

Removing thick amounts of clothing and blankets will inhibit the body to reduce its temperature

(Carpenito-Moyet,2008)

Temperature <37.8c

Mr Hays isn’t flushed or sweating and is comfortable

Maintain consistent room temperature

Provide air conditioning / fan or a cool bath to decrease temperature

(Carpenito-Moyet,2008)

Temperature of the environment deeply affects body temperature

(Carpenito-Moyet,2008)

Room temperature of around 22.2c

(Carpenito-Moyet,2008)