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