9.8 Putting It All Together

Client Scenario

Mrs. Charles is a 74-year-old woman admitted to the medical-surgical floor with pneumonia. She has a history of right sided hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing) as a result of a cerebral vascular accident three years ago. Upon assessment, the client has a RR of 22 and rhonchi in her upper lobes. Her oxygenation saturation is 89% on room air, and she is utilizing accessory muscles during respiration.

Applying the Nursing Process

Assessment: The nurse notes that the client demonstrates tachypnea, hypoxemia, and abnormal breath sounds. She has a history of hemiplegia and dysphagia.

Based on the assessment information that has been gathered, the following nursing care plan is created for Mrs. Charles.

Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus as evidenced by adventitious breath sounds and alteration in respiratory rate.

Overall Goal: The client will maintain patent airway at all times.

SMART Expected Outcome: Mrs. Charles will effectively clear secretions throughout the hospitalization.

Planning and Implementing Nursing Interventions:

The nurse will assess the client’s respiratory rate, rhythm, and depth of respiration. The nurse will assess and instruct the client on the methods of appropriate cough and deep breathing. The nurse will auscultate lung fields to identify areas of worsening airflow. The nurse will elevate the client’s head of bed and encourage hydration to thin secretions. The nurse will instruct the client regarding proper deep breathing exercises and encourage assisted ambulation to mobilize secretions.

Sample Documentation:

Mrs. Charles has ineffective airway clearance with suspected aspiration secondary to dysphagia. The client has rhonchi in bilateral upper lobes, decreased oxygenation, and tachypnea. In order to enhance airway clearance and mobilize secretions, the client has received instruction to maintain fluid intake, increase ambulation, and cough and deep breathe. The client will maintain an elevated head of bed to encourage ease of respiration and will be assessed frequently for worsening respiratory status.

Evaluation:

During the client’s hospitalization, she maintains a patent airway and effectively clears secretions resulting in improved respiratory effort and overall function. The SMART outcome was “met.”