Water, hydration, and health. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). d. Anterior then posterior What is the most appropriate action by the nurse? Fluids help the kidneys filter and flush waste products preventing renal and urinary infections. b. St. Louis, MO: Elsevier. The nurse can install an air filter machine that will help create a dust-free environment that will be ideal for a patient with pneumonia. She earned her BSN at Western Governors University. Has been NPO since midnight in preparation for surgery Nursing care plans: Diagnoses, interventions, & outcomes. 7. (2020, June 15). Buy on Amazon. Steroids: To reduce the inflammation in the lungs. 8. b. Immunocompromised people are more susceptible to fungal pneumonia than healthy individuals. Increased fluid intake decreases viscosity of sputum, making it easier to lift and cough up. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. What priority discharge teaching should the nurse provide? Ensure that the patient verbalizes knowledge of these activities and their reasons and returns demonstrations appropriately. Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Discontinue if SpO2 level is above the target range, or as ordered by the physician. Monitor for respiratory changes.Changes in respiratory rate, rhythm, and depth can be subtle or appear suddenly. Lung abscess. Streptococcus pneumoniae is the causative agent for most of the cases of adult community-acquired pneumonia. The pH is also decreased in mixed venous blood gases because of the higher partial pressure of carbon dioxide in venous blood (PvCO2). b. The body needs more oxygen since it is trying to fight the virus or bacteria causing pneumonia. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? Using a sphygmometer, auscultate the patients breath sounds for at least every 4 hours. - A nurse should be aware of some of the common side effects of antitubercular drugs like rifampin, one of which is orange discoloration of body fluids such as urine, sweat, tears, and sputum. 2. Bacterial pneumonias affect all or part of one lobe of the lung, whereas viral pneumonias occur diffusely throughout the lung. Nursing Diagnosis related to --- as evidence by---Impaired gas exchange related to inflammation of airways, fluid-filled alveoli, and collection of mucus in the airway as evidenced by dyspnea and tachypnea (Carpenito, 2021). Use 1 for the first action and 7 for the last action. This is an expected finding with pneumonia, but should not continue to rise with treatment. Select all that apply. This can lead to hypoxia (lack of oxygen), and possibly tissue damage. Signs and symptoms of respiratory distress include agitation, anxiety, mental status changes, shortness of breath, tachypnea, and use of accessory respiratory muscles. Patients who are weak or lack a cough reflex may not be able to do so. f. Hyperresonance 3.7 Risk for Deficient Fluid Volume. On inspection, the throat is reddened and edematous with patchy yellow exudates. c. Keep a same-size or larger replacement tube at the bedside. usually occur after aspiration of oral pharyngeal flora or gastric contents in persons whose resistance is altered or whose cough mechanism is impaired, Bacteria enter the lower respiratory tract via three routes. Change ventilation tubing according to agency guidelines. Obtain the supplies that will be used. b. Respiratory distress requires immediate medical intervention. d. Auscultation. b. The nurse is providing postoperative care for a patient three days after a total knee arthroplasty. Number the following actions in the order the nurse should complete them. c. Terminal structures of the respiratory tract Productive cough (viral pneumonia may present as dry cough at first). Doing activities at the same time will only increase the demands of oxygen in the body, and patients with pneumonia cannot tolerate it. Suction as needed.Patients who have a tracheostomy may need frequent suctioning to keep airways clear. 1) SpO2 of 85% 2) PaCO2 of 65 mm Hg 3) Thick yellow mucus expectorant 4) Respiratory rate of 24 breaths/minute 5) Dullness to percussion over the affected area Click the card to flip Gas exchange is the passage of oxygen and carbon dioxide in opposite directions across the alveolocapillary membrane (Miller-Keane, 2003). Concept Map-AHI - Concept Mapping Nursing diagnosis: Impaired gas exchange pertaining to medical - Studocu concept mapping concept mapping nursing diagnosis: impaired gas exchange pertaining to medical diagnosis of coughing, copd and pneumonia and smoking history. If the patients condition worsens or lab values do not improve, they may not be receiving the correct antibiotic for the bacteria causing infection. They will further understand the topic since they already have an idea of what is it about. d. Inform the patient that radiation isolation for 24 hours after the test is necessary. Cough and sore throat Increase heat and humidity if patient has persistent secretions. a. The parietal pleura is a membrane that lines the chest cavity. Allow 90 minutes for. e. FVC Older adults may be confused or disoriented and have a low-grade fever but few other signs and symptoms. Priority: Management of pneumonia and dehydration. Also, they will effectively help spread the disease process since they know the mode of transmission and how to break the cycle of transmitting it to other family members. d. Patient receiving oxygen therapy. Organizing the tasks will provide a sufficient rest period for the patient. Select all that apply. Coughing and difficulty of breathing may cause. Course crackles sound like blowing through a straw under water and occur in pneumonia when there is severe congestion. These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect the patients' activity tolerance. d. Apply an ice pack to the back of the neck. If a patient is immobile they must be repositioned every 2 hours to maintain skin integrity. Identify candidates for surgical intervention who are at increased risk for nosocomial pneumonia. Wear gloves on both hands when handling the cannula or when handling ventilation tubing. What are possible explanations for this behavior? Volume of air inhaled and exhaled with each breath d. Activity-exercise: Decreased exercise or activity tolerance, dyspnea on rest or exertion, sedentary habits 5) Minimize time in congregate settings. Suction the mouth or the oral airway as needed. Otherwise, scroll down to view this completed care plan. Those at higher risk, such as the very young or old, patients with compromised immune systems, or who already have a respiratory comorbidity, may require inpatient care and treatment. Level of the patient's pain The bacteria attach to the cilia of the respiratory tract and release toxins that damage the cilia, causing inflammation and swelling. Gravity and hydrostatic pressure in this position promote perfusion and ventilation matching. c. Check the position of the probe on the finger or earlobe. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before eliciting additional help. k. Value-belief, Risk Factor for or Response to Respiratory Problem The most common is a cough producing purulent sputum (often dark brown) that is foul smelling and foul tasting. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). She found a passion in the ER and has stayed in this department for 30 years. f. Cognitive-perceptual: Decreased cognitive function with restlessness, irritability. Remove excessive clothing, blankets and linens. Dont forget to include some emergency contact numbers just in case there is an emergency. The nurse is preparing the patient for and will assist the health care provider with a thoracentesis in the patient's room. The patient receives 1 point for each criterion: confusion (compared to baseline); BUN greater than 20 mg/dL; respiratory rate greater than or equal to 30 breaths/min; systolic BP of less than 90 mm Hg; and age greater than or equal to 65 yrs. Suctioning keeps the airway clear by removing secretions. Pulmonary activities that help prevent infection/pneumonia include deep breathing, coughing, turning in bed, splinting wounds before breathing exercises, walking, maintaining adequate oral fluid intake, and using a hyperinflation device. Assist the patient when they are doing their activities of daily living. 2. Usual PaO2 levels are expected in patients 60 years of age or younger. The prognosis of a patient with PE is good if therapy is started immediately. Change the tube every 3 days. 6) a. Verify breath sounds in all fields. RR 24 Pulmonary embolism does not manifest in this way, and assessing for it is not required in this case. The nurse determines effective discharge teaching for a patient with pneumonia when the patient makes which statement? 3. b. Unstable hemodynamics Patients should not use cough suppressants and antihistamines because they are ineffective and may induce coughing episodes. The immunity will not protect for several years, as new strains of influenza may develop each year. Administer supplemental oxygen, as prescribed. 1. Arterial blood gases measure the levels of oxygen and carbon dioxide in the blood. This is most common in intensive care units usually resulting from intubation and ventilation support. An indicator of inadequate fluid volume is a urine output of less than 30 ml/hr for 2 consecutive hours. b. Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient? The nurse presents education about pertussis for a group of nursing students and includes which information? Impaired gas exchange is the state in which there is an excess or deficit in oxygenation or in the elimination of carbon dioxide at the level of the alveolocapillary membrane. Teach the proper technique of doing pursed-lip breathing, various ways of relaxation, and abdominal breathing. It does not respond to antibiotics; therefore, the management is focused on symptom control and may also include the use of an antiviral drug. Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by shortness of breath, low SPO2, and bacteria found in sputum culture. g. Self-perception-self-concept 3. Help the patient get into a comfortable position, usually the half-Fowler position. Nurses also play a role in preventing pneumonia through education. 4. 2) d. Direct the family members to the waiting room. Sleep disturbance related to dyspnea or discomfort 6. Teach the patient to splint the chest with a pillow, folded blanket, or folded arms. Alveolar sacs are terminal structures of the respiratory tract, where gas exchange takes place. Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. (1) Aspiration of gastric acid (the most common route), resulting in toxic damage to the lungs, (2) obstruction (foreign bodies or fluids), and. Physical examination of the lungs indicates dullness to percussion and decreased breath sounds on auscultation over the involved segment of the lung. 2. Place the patient in a comfortable position. A) 1, 2, 3, 4 These critically ill patients have a high mortality rate of 25-50%. 26: Upper Respiratory Problems / CH. Heavy tobacco and/or alcohol use Basket stars are active at night. Related to: As evidenced by: obstruction of airways, bronchospasm, air trapping, right-to-left shunting, ventilation/perfusion mismatching, inability to move secretions, hypoventilation . Bacterial Pneumonia. An open reduction and internal fixation of the tibia were performed the day of the trauma. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. Impaired gas exchange is a risk nursing diagnosis for pneumonia. g. Fine crackles Report significant findings. The trachea connects the larynx and the bronchi. A) Sit the patient up in bed as tolerated and apply Fever and vomiting are not manifestations of a lung abscess. To facilitate the body in cooling down and to provide comfort. Assess for mental status changes. Sputum for Gram stain and culture and sensitivity tests: Sputum is obtained from the lower respiratory tract before starting antibiotic therapy to identify the causative organisms. A bronchoscopy requires NPO status for 6 to 12 hours before the test, and invasive tests (e.g., bronchoscopy, mediastinoscopy, biopsies) require informed consent that the HCP should obtain from the patient. d. Notify the health care provider of the change in baseline PaO2. Maintain intravenous (IV) fluid therapy as prescribed. F. A. Davis Company. c. Empyema c. A nasogastric tube with orders for tube feedings 2. Popkin, B. M., DAnci, K. E., & Rosenberg, I. H. (2010). b. a. Assess the patient for iodine allergy. Diminished breath sounds are linked with poor ventilation. Periorbital and facial edema reduced by about half since second hospital day Pink, frothy sputum would be present in CHF and pulmonary edema. Use of accessory respiratory muscles (scalene, sternocleidomastoid, external intercostal muscles), decreased chest expansion due to pleural pain, dullness when tapping on affected (consolidated) areas. Ensure that the patient performs deep breathing with coughing exercises at least every 2 hours. Deficient knowledge (patient, family) regarding condition, treatment, and self-care strategies (Including information about home management of COPD) 7. She received her RN license in 1997. Look for and report urine output less than 30 ml/hr or 0.5 ml/kg/hr. People with community-acquired pneumonia usually do not need to be hospitalized unless an underlying condition such as chronic obstructive pulmonary disease (COPD), heart disease or diabetes mellitus, or a weakened immune system complicates the disease. The nurse is caring for a patient who experiences shortness of breath, severe productive cough, and fever. a. Undergo weekly immunotherapy. Pneumonia is the second most common nosocomial infection in critically ill patients and a leading cause of death from hospital-acquired infections. 5) e. Observe for signs of hypoxia during the procedure. c) 5. c. Drainage on the nasal dressing d. Thoracic cage. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pneumonia, https://my.clevelandclinic.org/health/diseases/4471-pneumonia, https://doi.org/10.1111/j.1753-4887.2010.00304.x, https://emedicine.medscape.com/article/234753-overview#a4, Hypertension Nursing Diagnosis & Care Plan, The ABCs of Evidence-Based Practice in Nursing, Diminished lung sounds or crackles/rhonchi, Patient will demonstrate appropriate airway clearance techniques, Patient will display improvement in airway clearance as evidenced by clear breath sounds and an even and unlabored respiratory rate, Hypoventilation causing a lack of oxygen delivery, Patient will display appropriate oxygenation through ABGs within normal limits, Patient will demonstrate appropriate actions to promote ventilation and oxygenation, Inadequate primary defenses: decreased ciliary action, respiratory secretions, Invasive procedures: suctioning, intubation, Patient will not develop a secondary infection or sepsis, Patient will display improvement in infection evidenced by vital signs and lab values within normal limits. Discharge from the hospital is expected if the patient has at least five of the following indicators: temperature 37.7C or less, heart rate 100 beats/minute or less, heart rate 24 breaths/minute or less, systolic blood pressure (SBP) 90 mm Hg or more, oxygen saturation greater than 92%, and ability to maintain oral intake. The nurse suspects which diagnosis? Line the lung pleura document.getElementById("ak_js_1").setAttribute("value",(new Date()).getTime()); This site uses Akismet to reduce spam. a. An ET tube has a higher risk of tracheal pressure necrosis. Empyema is a collection of pus in the thoracic cavity. Select all that apply. a. Decreased immunoglobulin A (IgA) decreases the resistance to infection. e. Posterior then anterior. Blood culture and sensitivity: To determine the presence of bacteremia and identify the causative organism. Attempt to replace the tube. Patient Profile F.N. Buy on Amazon, Silvestri, L. A. To help clear thick phlegm that the patient is unable to expectorate. This is needed to help the patient conserve his or her energy and also effective relaxation when the patient feels anxious and having a hard time concentrating and breathing. 3 Pneumonia in the immunocompromised individual 4 Assessment of pneumonia 5 Diagnostic test for pneumonia 6 Nursing Diagnosis of pneumonia 6.1 Risk for Infection (nosocomial pneumonia) 6.2 Impaired Gas Exchange due to pneumonic condition 6.3 Ineffective clearance of the airway 6.4 Deficient fluid volume Community acquired pneumonias f. Instruct the patient not to talk during the procedure. Maximum amount of air that can be exhaled after maximum inspiration The visceral pleura lines the lungs and forms a closed, double-walled sac with the parietal pleura. This can occur for various reasons, including but not limited to: lung disease, heart failure, and pneumonia. A nurse has been caring for a patient with tuberculosis (TB) and has a TB skin test performed. Perform steam inhalation or nebulization as required/ prescribed. c. Take the specimen immediately to the laboratory in an iced container. Proper nutrition promotes energy and supports the immune system. Base to apex a. Dullness and hyperresonance are found in the lungs using percussion, not the other assessment techniques. The home health nurse provides which instruction for a patient being treated for pneumonia? 6. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. c. Place the patient in high Fowler's position. c. "An annual vaccination is not necessary because previous immunity will protect you for several years." 3. Start oxygen administration by nasal cannula at 2 L/min. Objective Data Chronic hypoxemia Encourage fluid intake and nutrition.Hydration is vital to prevent dehydration and supports homeostasis. When is the nurse considered infected? Pneumonia may increase sputum production causing difficulty in clearing the airways. Individuals with depressed level of consciousness, advanced age, dysphagia, or a nasogastric (NG) or enteral tube are at increased risk for aspiration, which predisposes them to pneumonia. Which medication therapy does the nurse anticipate will be prescribed? Priority Decision: F.N. d. An ET tube is more likely to lead to lower respiratory tract infection. A 70-year-old patient presents to the emergency department with symptoms that indicate pneumonia. Pneumonia is an infection of the lungs that can be caused by bacteria, fungi, or viruses. a. Stridor These techniques mentioned will greatly help the patient to avoid respiratory distress and assist the body to take in oxygen and avoid hypoxia. Document the results in the patient's record. They are as follows: Ineffective Airway Clearance Impaired Gas Exchange Ineffective Breathing Pattern Risk for Infection Acute Pain Decreased Activity Tolerance Hyperthermia Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition: Less Than Body Requirements a. Suction the tracheostomy. Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). Pneumonia can be mild but can also be fatal if left untreated. Bronchoconstriction a. Pulmonary function test When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? 1. Although inadequately treated -hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. 2. of . Awakening with dyspnea, wheezing, or cough. A patient with a 10-year history of regular (three beers per week) alcohol consumption began taking rifampin to treat tuberculosis (TB). deep inspiratory crackles (rales) caused by respiratory secretions, and circumoral cyanosis (a late finding). Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? This intervention decreases pain during coughing, thereby promoting a more effective cough. If abnormal, the lungs are not oxygenating adequately causing poor perfusion of the tissues. Fatigue 4. d. Reflex bronchoconstriction. Nutrition reviews, 68(8), 439458. Amount of air remaining in lungs after forced expiration Community-Acquired Pneumonia. Monitor ABGs and oxygen saturation.Decreasing sp02 signifies hypoxia. e. Suction the tracheostomy tube when there is a moist cough or a decreased arterial oxygen saturation by pulse oximetry (SpO2). e. Rapid respiratory rate. Initially, oxygen is administered at low concentrations, and oxygen saturation is closely monitored. However, it is highly unlikely that TB has spread to the liver. This work is the product of the The treatment is macrolide (erythromycin, azithromycin [Zithromax]) antibiotics to minimize symptoms and prevent the spread of the disease. b. Identify and avoid triggers of the allergic reaction. If the patient is enteral fed, recommend continuous rather than bolus feeding. Air trapping RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. c. TLC: (2) Maximum amount of air lungs can contain Factors that increase the risk of nosocomial pneumonia in surgical patients include: older adults (older than 70 years), obesity, COPD, other chronic lung diseases (e.g., asthma), history of smoking, abnormal pulmonary function tests (especially decreased forced expiratory flow rate), intubation, and upper abdominal/thoracic surgery. Turbinates warm and moisturize inhaled air. (2020). Advised the patient to dispose of and let out the secretions. Trend and rate of development of the hyperkalemia patients with pneumonia need assistance when performing activities of daily living. - Manifestations of a lung abscess usually occur slowly over a period of weeks to months, especially if anaerobic organisms are the cause. 2018.03.29 NMNEC Leadership Council. A) Increasing fluids to at least 6 to 10 glasses/day, unless. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? a. d. Small airway closure earlier in expiration Monitor oximetry values; report O2 saturation of 92% or less. Assess the patients knowledge about Pneumonia. Nursing Diagnosis: Hyperthermia related to the disease process of bacterial pneumonia as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, and profuse sweating. Other antibiotics that may be used for pneumonia include doxycycline, levofloxacin, and combination of macrolide and beta-lactam (amoxicillin or amoxicillin/clavulanate known as Augmentin). 3. Implement precautions to prevent infection.Proper handwashing is the best way to prevent and control the spread of infection. 2/21/2019 Compiled by C Settley 10. e. Decreased functional immunoglobulin A (IgA). a. It is very important to take and record the patients respiratory assessment to make it a basis if there are any abnormal findings in the future. At the end of the span of care, the patient will be able to have an effective, regular, and improved respiratory pattern within a normal range (12-20 cycles per minute). d. Activity-exercise 5. Interstitial edema d. Bradycardia In general, any factor that alters the integrity of the lower airway, thereby inhibiting ciliary activity, increases the likelihood of pneumonia. Changes in behavior and mental status can be early signs of impaired gas exchange. He or she will also comply and participate in the special treatment program designed for his or her condition. 6. causing a clinical illness o Mandatory testing for health care professionals o Usually performed twice o Priority Nursing Diagnoses: Ineffective breathing pattern Ineffective airway clearance Impaired Gas . Outcomes Interventions Rationale with reference Eval of goal/outcomes Gas r/t alveolar- membrane AEB Positive for strep Bi-pap to maintain rhonchi diminished breath bilaterally. What should the nurse do when preparing a patient for a pulmonary angiogram? With acute bronchitis, clear sputum is often present, although some patients have purulent sputum. a. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. c. Determine the need for suctioning. d. Contain dead air that is not available for gas exchange. Allow the patient to have enough bed rest and avoid strenuous activities. d. Pleural friction rub. A relative increase in antibody titers indicates viral infection. Given a square matrix [A], write a single line MATLAB command that will create a new matrix [Aug] that consists of the original matrix [A] augmented by an identity matrix [I]. c. An electrolarynx held to the neck What is the first action the nurse should take? Select all that apply. Reports facial pain at a level of 6 on a 10-point scale The nurse expects which treatment plan? A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. It is important to pre-oxygenate the patient before the nurse suctions to avoid respiratory distress. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Chronic hypoxemia Decreased force of cough b. Surfactant 3. To determine the tracheal position, the nurse places the index fingers on either side of the trachea just above the suprasternal notch and gently presses backward. Nursing Care Plan 2 b. If the probe is intact at the site and perfusion is adequate, an ABG analysis will be ordered by the HCP to verify accuracy, and oxygen may be administered, depending on the patient's condition and the assessment of respiratory and cardiac status. These measures ensure consistency and accuracy of weight measurements. Arterial blood gas (ABG) values: May vary depending on extent of pulmonary involvement or other coexisting conditions. A patient with pneumonia shows inflammation in their lung parenchyma causing it to have. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration, and the nurse should monitor the patient's respiratory rate and rhythm and SpO2. An initial negative skin test should be repeated in 1 to 3 weeks and if the second test is negative, the individual can be considered uninfected. It is also inappropriate to advise the patient to stop taking antitubercular drugs. 6) The patient is infectious from the beginning of the first stage Bacteremia. This assessment monitors the trend in fluid volume. j. Coping-stress tolerance Please read our disclaimer. A 10-mm red indurated injection site could be a positive result for a nurse as an employee in a high-risk setting. Pneumonia: Bacterial or viral infections in the lungs . c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal fluid. As an Amazon Associate I earn from qualifying purchases. A patient with pneumonia is at high risk of getting fatigued and overexertion because of the increased need for oxygen demands in the body. The nurse explains that usual treatment includes b. Stridor The nurse identifies a nursing diagnosis of impaired gas exchange for a patient with pneumonia based on which physical assessment findings? high-pitched and inspiratory crackles (rales) that are amplified by coughing or heard only after coughing. Please follow your facilities guidelines, policies, and procedures. Nursing Diagnosis for Pleural Effusion Impaired Gas Exchange r/t decreased function of lung tissue Ineffective Breathing Pattern r/t compromised lung expansion Acute Pain r/t inflammatory process Anxiety r/t inability to take deep breaths Risk for infection r/t pooling of fluid in the lung space Nursing Care Plans for Pleural Effusion The type of antibiotic is determined after a sputum culture result is obtained and the specific type of bacteria is known. Remove unnecessary lines as soon as possible. Assess the patients vital signs at least every 4 hours. Patients who are weak or fatigued with an ineffective cough can be taught how to suction themselves. a. 3.1 Ineffective airway clearance. A) Admit the patient to the intensive care unit. c. Perform mouth care every 12 hours. The width of the chest is equal to the depth of the chest. Stop feeding when the patient is lying flat. Anatomy of the Respiratory System The respiratory system is composed of the nose, pharynx, larynx, trachea, bronchi, and lungs.
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