a patient has a tracheal artificial airway and is having non-productive coughs. upon ascultation of the lungs on the back, the student nurse hears coarse crackles and wheezing. when the student ascultates for the heart sounds, she cannot hear any because the crackles and wheezing sounds make it difficult for her to do so.
what should the student nurse do?
since the patient is having non-productive coughs, the sputum is ineffectively clearing from the patient's airway. the student can say so because there is lack of sputum present when the patient coughs, and crackles indicates this as well. the student should deep suction the artificial airway as necessary to remove the sputum effectively. the sputum removed should be observed for quantity and quality. to ensure the student nurse performed efficient suctioning, she should ascultate the lung sounds again to check for improvement.
*can this be put into ADPIE format?
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1 comment:
Anh, I think posting our personal clinical situations is a fabulous idea! It allows us to "see" through other student experiences as well as go through the process of ADPIE to provide the safest and most ideal care. Kudos to you, my friend! :)
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