SALMORIN 4F - Discusssion Board Post Operative Complications.pdf

BASHRACEL MARIE M. SALMORIN BSN 4F
Actual Diagnosis
Ine±ective airway clearance related to obstructive airway as evidenced by excessive
sputum; adventitious breath sounds; alteration in respiratory pattern; alteration in
respiratory rate; diminished breath sounds; dyspnea; ine±ective cough; orthopnea;
restlessness; wide-eyed look
Potential Diagnosis
Risk for deficient Fluid volume: Risk factor: inadequate intake of fluids
NURSING INTERVENTIONS
• Auscultate breath sounds every 1 to 4 hours. Breath sounds are normally clear or scattered
fine crackles at bases, which clear with deep breathing. The presence of coarse crackles
during late inspiration indicates fluid in the airway; wheezing indicates an airway
obstruction (Fauci et al, 2008).
• Monitor respiratory patterns, including rate, depth, and e±ort. A normal respiratory rate for
an adult without dyspnea is 12 to 16 breaths per minute (Bickley & Szilagyi, 2012). With
secretions in the airway, the respiratory rate will increase.