Case Study: Ineffective Airway Clearance and Self-Care for Respiratory Illness

Patient Information

63yo Jenny Johnson presents to your emergency room complaining that she is having trouble breathing.  The triage nurse places her in a room quickly, and she is assigned to you.  Jenny reports that she has had a cold for three days, but today feels much worse.  She is sitting upright and breathing rapidly. Jenny is pale and diaphoretic. Her VS are: T 101.5, P 118, R 32, BP 118/76.  SaO2 90% on room air. You place her on 2L of oxygen per NC and her SaO2 rises to 97%. Jenny is alert and oriented x 3, but has difficulty focusing on the questions you are asking.  Pupils are equal, round, reactive to light, and accommodative.  On auscultation, Jenny has coarse breath sounds in all lung fields, rhonchi which clear with coughing, and wheezes which do not.  Breath sounds are very diminished in the RLL.  Jenny reports having a cough for 2 days. She coughs frequently but does not bring anything up. The OTC cough medication she is taking does not seem to relieve the cough.  Heart rate is regular, tachycardic. Abdomen is soft and nontender with active bowel sounds in all four quadrants. Jenny denies nausea, vomiting, or diarrhea, but reports decreased appetite for several days.  Jenny moves all extremities equally and ambulates with a steady gait, although she became short of breath ambulating from the car to the ER admissions desk.  Jenny reports that she takes the following medications: “a blood pressure pill, a cholesterol pill, and an inhaler”. Jenny denies pain but states she is tired. A chest Xray, CBC, and BMP are ordered.  Her highest priority nursing diagnosis is:

 Ineffective Airway Clearance r/t thick, tenacious secretions and knowledge deficit regarding self-care for respiratory illness aeb diminished breath sounds in RLL, nonproductive cough, tachypnea, taking OTC cough suppressant;

LTG (aimed to correct diagnosis): Client will effectively clear airway within 24 hours, as evidenced by air movement throughout lung fields on auscultation

STG: (aimed to correct etiology) Client’s cough will produce mucus thin enough to expectorate within 4 hours

STG: Client will explain how hydration improves effectiveness of cough, fluid requirements during respiratory illness, and how cough suppressants decrease effectiveness of cough within 6 hours

1. Make a list of at least 4 nursing actions (interventions) that you believe will help Mrs. Johnson to achieve the goals above.  Label the interventions dependent , independent, or interdependent. Place a * next to the interventions that may be delegated to unlicensed assistive personnel.

Example: Bathe patient daily with antibacterial soap-independent* (This is an independent intervention that may be delegated to a UAP)

1. Would the same interventions work if your client had difficulty clearing her airway due to an inflammatory response in the pharynx (swelling in the throat)?  Why or why not?

2. Some care planning references list assessments as possible interventions.  Assessment alone, however, will not correct a problem.  Rewrite each of the following assessments as interventions. In other words-what are you looking for and what will you do if you find it?

Example: Assess vital signs frequently. Rewrite as: Notify provider if pulse >100bpm or blood pressure <100 systolic or 60 diastolic.

1. How do you know that the interventions you selected for this patient in question 1 will work?  Find a reference to at least one research study that supports one of your interventions.