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ineffective airway clearance - CHAPTER 48 Oxygenation...

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CONCEPT MAP Ineffective Airway Clearance temperature; fatigue; rapid, labored respirations; mild dehydration. "Bad cold" x several weeks. Dieting for several months & skipping meals. Works full-time job as secretary, college classes 2x/week. Smokes, 21 pack/years. • Assist to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed • Encourage her to take several deep breaths • Encourage her to take a deep breath, hold for 2 seconds, and cough two or three time in succession • Encourage use of incentive spirometry, as appropriate • Promote systemic fluid hydration, as appropriate • Instruct about importance of leaving oxygen delivery device on • Periodically check oxygen delivery device to ensure that the prescribed concentration is being delivered • Observe for signs of oxygen-induced hypoventilation • Monitor rate, rhythm, depth, and effort of respirations • Note chest movement, watching for symmetry, use of
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