Question

Mr. S.L is a 79-year-old African American retired maintenance worker, with a 10-year history of COPD and HTN. He was admitted to a medical-surgical unit via ambulance from his home in Bowie, MD with a diagnosis of Pneumonia. His three grown children who live out of state are gainfully employed and are the pride of his life. His wife died a year ago and his Christianity beliefs and the loving support of his children are his coping strategies.

On admission, he states that he hasn’t been feeling well for 3-4 days, complained of dyspnea, generalized body pain, fatigue, and a productive cough of yellow colored sputum. He has not slept in 2 nights, is agitated, anxious about his health and reported feeling weak. Mr. Lawson has little appetite and is mostly eating soup even though the doctor ordered a regular diet. He is alert and oriented x 4, continent of bowel and bladder and on bed rest due to weakness and unsteady gait.

Physical assessment reveals B/P 168/90; pulse 104; respirations 26; temperature 98.9 F; oxygen saturation 93% on o2 2L via NC with diminished breath sounds bilateral and expiratory wheezing on auscultation. Bowel sounds are present on all four quadrants, heart sounds are regular and his skin is intact. I.V. antibiotics are ordered and started.

Goals/Outcomes

Goal: Mr. S.L will maintain clear, open airways as evidenced by normal breath sounds and normal rate of respirations by discharge.

Outcomes:

1.) Mr. S.L will be able to maintain airway patency by the end of the shift.

2.) Mr. S.L will be able to demonstrate behaviors to improve or maintain clear airway.

3.) **Can someone help me come up with a third outcome please?**

Interventions

1.) Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on over-bed table, or sitting on edge of bed (independent intervention)

2.) Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort (independent intervention)

3.) Administer antimicrobials (dependent intervention)

4.) Monitor and graph serial ABGs, pulse oximetry, and chest (dependent intervention)

5.) Assist with respiratory treatments, such as spirometry and chest physiotherapy (collaborative intervention)

6.) Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier (collaborative intervention)

INSTRUCTIONS: Utilizing therapeutic communication concepts, explain how you'll implement the interventions that will enable you to achieve the stated goal/outcomes.

Answer 1

3 Mr SL will be able to experience clear breath sounds.

1 Assist the patient to sitting position with head slightly flexed,shoulders relaxed and knees flexed to allow for adequate chest expansion.

2 Instruct the patient to inhale deeply ,bend forward slightly and perform three or four huffs to prevent airway collapse during exhalation.

3 Instruct the patient to follow coughing with several maximum inhalation breaths to reoxygenate the lungs.

4Position patient to maximize ventillation potential.

5 Perform chest physiotherapy to use effect of gravity in removing secretions.

6 Instruct the patient to follow coughing with several maximal inhalation breaths to reoxygenate the lungs.