When monitoring for ineffective [blank_start]airway[blank_end] clearance the nurse should
Monitor skin [blank_start]colour[blank_end], temp & level of [blank_start]consciousness[blank_end] (LOC)
Cyanosis, cool clammy skin & decreased LOC indicates worsening [blank_start]hypoxia[blank_end]
Assess ABG results & SpO2 readings
Notify medical team of [blank_start]abnormal[blank_end] values/ change in status
Responda
airway
colour
consciousness
hypoxia
abnormal
Questão 2
Questão
Interventions for ineffective airway clearance due to asthma
Interventions:
Place in [blank_start]Fowler’s[blank_end] or the [blank_start]tripod[blank_end] position to facilitate breathing &
lung expansion (assists in reducing the [blank_start]WOB[blank_end])
Administer O2 as ordered
Administer medications as ordered
Initiate or assist with chest physiotherapy: postural drainage &
percussion to facilitate movement of [blank_start]secretions[blank_end]
Increase patient’s [blank_start]fluid[blank_end] intake to reduce viscosity of secretions
Provide endotracheal [blank_start]suctioning[blank_end] as necessary
Responda
Fowler’s
tripod
WOB
secretions
fluid
suctioning
Questão 3
Questão
Ineffective breathing [blank_start]pattern[blank_end] due to acute asthma
Interventions:
Provide [blank_start]rest[blank_end] between activities
Teach breathing techniques to control breathing pattern (i.e [blank_start]pursed[blank_end] lip or abdominal breathing)
Responda
pattern
rest
pursed
Questão 4
Questão
Patient education:
Assess the patient’s [blank_start]understanding[blank_end] of asthma and their medications
Ask them to [blank_start]show[blank_end] you how they use their meds
Involve the [blank_start]family[blank_end] in this education
Provide [blank_start]verbal[blank_end] and [blank_start]written[blank_end] instructions
Consider a referral to other supports or educational services
Responda
understanding
show
family
verbal
written
Questão 5
Questão
Asthma first aid
1) Sit the person upright. Provide [blank_start]reassurance[blank_end].
2) Give [blank_start]4[blank_end] puffs of [blank_start]salbutamol[blank_end]. Use a [blank_start]spacer[blank_end], if available.
[blank_start]1[blank_end] Puff at a time with [blank_start]4[blank_end] breaths between each puff.
3) Wait [blank_start]4[blank_end] minutes. If the person still cannot breath normally, give [blank_start]4[blank_end] additional puffs.
4) If the person still cannot breath normally - contact 000.
Keep giving [blank_start]4[blank_end] puffs every [blank_start]4[blank_end] minutes until the ambulance arrives.
Responda
reassurance
4
salbutamol
spacer
1
4
4
4
4
4
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