This is the first NPR I passed this semester. Format isn't the same as you can see, but I'm sure you will be able to figure it out though. This NPR was submitted to professor McFadden.
Ineffective airway clearance related to stasis of secretions secondary to pneumonia
Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms including bacteria. Pneumonia affects both ventilation and diffusion. An inflammatory reaction can occur in alveoli, producing exudates that interfere with the diffusion of oxygen and carbon dioxide. White blood cells also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lungs are not adequately ventilated because of secretions and mucosal edema that causes partial occlusion of the bronchi or alveoli.(#4, 634)
Ineffective airway clearance is the state in which an individual experiences a threat to respiratory status related to inability to cough effectively.Mrs. PT has pneumonia; she has a stasis of pulmonary secretions. Therefore she has an ineffective airway clearance.



COPD (o)
Pneumonia (o)
Productive cough (o)
Rhonchi (o)
Shortness of breath when talking and coughing (o)
Use of accessory muscles (o)
Pulse ox – 91 (o)
O2 3L/min nasal cannula (o)
Pulse ox drops to 80 when nasal cannula is off for more then 5 min. (o)
Restlessness (o)
Anorexia, unable to access amount consumed due to time restrains, however, patient reported she doesn’t have an appetite and eats very little (s)
Impaired physical mobility (o)
Weakness (o)
Pallor (o)
Irregular labored respirations (o)
Yellow thick sputum with small amount of blood (o)
Age – 81 (o)
Cancer (o)



Goal: The patient will maintain patent airway while in my care.
1a.Assess respirations.
1b. Assess pulse
1c. Assess blood pressure
1d. Assess temperature
1e. Assess pain
2. Assess oxygen saturation.
3. Auscultate lung sounds
4. Assess mental status
5. Assess skin color
6. Assess coughing and sputum.
7. Assess lab values
8. Educate patient and family about therapeutic effects and side effects of oxygen therapy Maintain oxygen therapy as prescribed (3L/min via nasal cannula)
Monitor for therapeutic effects
9. Provide appropriate positioning
10. Provide chest PT
11. Teach deep breathing and coughing
12. Increase fluid intake (2-3L/day small frequents amounts)
13. Promote rest
14. Teach patient and family about therapeutic effects and side effects of Vancomycin. Administer Vancomycin 500mg q6h. Monitor for therapeutic effects. Monitor for side effects
15. Teach patient and family about therapeutic and side effects. Administer DuoNeb as prescribed (3mL QID). Monitor for therapeutic effects. Monitor for side effects
16. Teach patient and family about therapeutic effects and side effects of Aranesp. Administer Aranesp as prescribed (5000 units/wk)
Monitor for therapeutic effects.
Monitor for side effects
17. Teach patient and family about therapeutic effects and side effects of Ambien. Administer Ambien as prescribed (10mg prn HS) monitor for therapeutic effects and side effects.
18. Maintain adequate nutrition
19. Provide teaching
The only change in goal and care plan she wanted me to make is to list therapeutic and side effects of the medications in steps 14-17



1a. Dyspnea, use of accessory muscles, difficulty breathing, irregular respirations, and other changes in respirations are associated with pneumonia. Respiratory symptoms may be the only signs of pneumonia in patients with COPD (#7, 724) (I don't know what she meant by it, but she wrote "How does hypoxia effects respirations?" I thought it was obvious, but I guess she wanted me to elaborate more on it)
1b. Dysrhythmia is a sign of hypoxemia. Hypoxemia usually leads to hypoxia, which is life threatening. Tachycardia is a sign of hypoxia. (#7, 724)
1c. Unusual increase in blood pressure may be a sign of hypoxia (#7, 724)
1d. Patients with certain types of pneumonia (pneumococcal) usually have a sudden onset of chills and rapidly rising fever (38.5 to 40.5 C or 101 to 105 F) Patients who have conditions such as cancer and have a suppressed immune system are more likely to have fever(#7, 636)
1e. Patients with pneumonia often have pleuritic chest pain that is aggravated by deep breathing and coughing. Some patients experience signs of respiratory tract infection such as sore throat (#7, 636)
2. Pulse oximetry is performed to determine the need for oxygen and to evaluate the effectiveness of the therapy. Pulse oximetry can help to determine the need for oxygen therapy. High concentration of oxygen is contraindicated in the patients with COPD because it may worsen alveolar ventilation by decreasing the patient’s ventilatory drive, leading to further respiratory decompensation. However if oxygen saturation is too low, more aggressive respiratory support measures may be required. (#7, 638)
3. Adventitious lung sounds such as rhonchi and crackles are often present during pneumonia and indicate presence of fluid and pulmonary secretions in the lungs. (#7, 643)
4. Changes in mental status, such as impaired judgment, agitation, disorientation, confusion, lethargy, and coma are signs of hypoxia. If hypoxia is not identified and treated early many complications and even death may occur. (#7, 724)
5. In severe pneumonia, cheeks are flushed and lips and nail beds are cyanotic demonstrating central cyanosis (A late sign of hypoxia) (#7, 636)
6. Patients with pneumonia often have cough. When cough is productive and sputum is expectorated, sputum is often purulent. Rusty, blood tinged sputum may be expectorated with streptococcal (pneumococcal) staphylococcal, and Klebsiela pneumonia.Purulent sputum may be the only signs of pneumonia in patients with COPD (#7, 640)
7. Blood culture may be taken to determine whether bacteremia is present (#6, 670). Sputum culture is used to diagnose pneumonia. Gram stain is the first step in the microbiologic analysis of sputum. This may be used to guide drug therapy until the C&S report is complete. Determinations of bacterial sensitivity to various antibiotics are performed to identify the most appropriate antimicrobial drug therapy (#6, 716) Blood smear provides information concerning drugs and diseases that affect the RBCs and WBCs. Further more many diseases can be diagnosed by an examination of the peripheral blood smear. (#6, 672)
8. A high concentration of oxygen is contraindicated for patient with COPD because it worsens alveolar ventilation by decreasing the patient’s ventilatory drive, leading to further respiratory decompensation. Not enough oxygen however may cause oxygen saturation to drop. (#7, 638)
9. The patient should assume a comfortable position (semi-Fowler’s or high-Fowlers) and change positions frequently to enhance secretion clearance and ventilation and perfusion in the lungs. (#7, 640)When the patient is in Fowler’s position, gravity pulls the diaphragm downward, allowing greater chest expansion and lung ventilation. (#3, 1132)
10. Chest physiotherapy is important in loosing and mobilizing secretions. Indications for physiotherapy include sputum retention not responding to spontaneous or direct cough, a history of pulmonary problems previous treated with chest physiotherapy, continued evidence of retained secretions (decreased or abnormal breath sounds, change in vital signs), abnormal chest x-ray findings. (#7, 640)
11. Lung expansion maneuvers, such as deep breathing may induce a cough. A direct cough may be necessary to improve airway patency. (#7, 640)
12. Hydration is a necessary part of therapy, because fever and tachypnea may result in insensible fluid loss.
Adequate hydration can also thiner and loosen pulmonary secretions Hydration must be achieved more slowly and with careful monitoring in older adults and patients with preexisting conditions, such as CHF. (#7, 640)
13. It is important to instruct patient not to overexert herself and engage in only moderate activity to preserve energy. (#7, 640)
14. Vancomycin is a bactericidal. It inhibits cell wall synthesis of susceptible organisms, causing cell death. It is given to patients with staphylococci infection who cannot receive or failed to respond to penicillin and cephalosporins. (#5, 48)
15. DuoNeb is a bronchodilator that relaxes muscles in the airways and increase air flow to the lungs.DuoNeb is used to prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition. (#1)
16. Aranesp is a medication used for treating anemia in people who are undergoing chemotherapy or have chronic kidney failure. It is a man-made version of a human protein that stimulates the production of red blood cells by the bone marrow (#5)
17. Ambien is a sedative-hypnotic, or sleep medicine. It works by helping to increase certain natural chemicals in the brain that cause sleep. (#4, 183)
18. Many patients with shortness of breath and fatigue have a decreased appetite and consume only fluids. Proteins however are needed to fight the infection. Supplements such as Ensure might be used to increase caloric intake.(#7, 640)
19. The patient and her family need information about factors that may have contributed to development of pneumonia and strategies to promote recovery and prevent recurrence. (#7, 641)


1a. Assessed respiration: Semi-Fowler’s position: Rate – 22/min, regular, shallow.
Use of accessory muscles. Shortness of breath when talking and coughingSitting in a chair: rate-20/min, regular, use of accessory muscles. Depth became deeper while in the chair.
1b. Assessed pulse: Rate-86.
Rhythm- regularVolume- weak
1c. Assessed blood pressure of 130/64
1d. Assessed temperature of 96.3 at 9:30 and 96.5 at 11:00. (She wrote "do not record readings this low. Must take again or use a diff. route" I took temperature orally, and the patient was mouth breather, should've taken axillary and added 1 to the result)
1e. Assessed pain of 4. Patient described it as sharp, stated it “disappears and comes back” when she moves around. Patient described the location as being in the back of the groin.
2. Assessed oxygen saturation of 91 when in semi-fowler’s position, 93 in sitting position and 94 after receiving bronchodilators. All readings were taken while the patient was receiving 02 at 3L/min via nasal cannula.
3. Assessed lung sounds. Rhonchi before receiving bronchodilators and clear after bronchodilators were administered.
4. Patient was alert and oriented X 3
5. Skin appeared pale while in semi-Fowler’s position, however pink color returned after patient was sited in the chair and received bronchodilators
6. Patient had a productive cough, was able to expectorate sputum.
7. Blood culture was not taken. Sputum culture showed staphylococci bacterial infection. RBC count is 3.70L. WBC count is 3.6L. HGB is 10.8L, HCT is 34.6
8. Oxygen was given at 3L/min by nasal cannula. I taught the patient about therapeutic effects and side effects. Explained the need to maintain oxygen therapy as prescribed and not to increase the dose unless the condition worsens and more oxygen is needed to maintain adequate oxygenation. Monitored therapeutic effects.
9. Head of the bed was elevated to position the patient in low-Fowler’s position. Was later transferred to the chair.
10. Provided chest physiotherapy during bed-bath.
11. Taught to deep breath and cough during the bed-bath.
12. Explained the need to increase fluid intake, the patient drank frequently, small amounts of water to prevent fluid overload.
13. Provided bed-bath, patient brushed her teeth, the rest of the am care was done by me. Cut food for the patient.
14. Explained to the patient importance of following doctor’s orders. Explained how Vancomycin can help to kill bacteria causing pneumonia and how bacteria can become resistant to the Vancomycin if treatment is stopped before all pneumonia causing bacteria are dead. Vancomycin was administered by primary nurse Unable to access the therapeutic effects due to time restrains. No common side effects have been reported. The patient had no signs of allergic reaction to Vancomycin
15. Taught patient about bronchdialecting effects of DuoNeb listed side effects and sign of allergic reaction. Advised to check with your doctor if any of these common side effects persist or become bothersome: Coughing, dizziness, dry mouth, headache, nervousness, sinus inflammation, sore throat.
Advised to seek medical attention right away if any of these severe side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); chest pain; fast or irregular heartbeat; new or worsening breathing problems; pounding in the chest; shortness of breath; swelling of the arms or legs; tremors; unexplained hoarseness; wheezing. DuoNeb was administered by the nurse. I monitored therapeutic effects, and side effects.
16. Explained the effects of Aranesp and the importance of having sufficient RBC count in oxygen transport. Listed side effects and explained that the patient should be aware of the signs of CVA and MI since they are adverse effects of Aranesp. Aranesp was administered by primary nurse. Was unable to monitor therapeutic effect due to time restraint.Monitored for side effects
17. I taught the patient about therapeutic effects of Ambien and the importance of having a good night sleep in order to maintain active and productive life style. I also explained the importance of safe use of sleep medications and effects of other prescribed medications on sleep. Listed side effects of Ambien such as memory loss, anxiety, depression, agitation, aggression, suicidal thoughts. Ambien was administered by primary nurse.
Was unable to assess the therapeutic effects myself due to time restraints however patient was able to explain that Ambien was not effective.Was unable to monitor for immediate side effects, however I asked the patient to recall if she had any side effects of this medication.
18. Patient was served food rich in proteins. Food was cut for the patient to conserve her energy. Some of the food was removed from the tray and saved for later
19. Taught about factors that may contribute to development of pneumonia and strategies to promote recovery and prevent recurrence, such as hydration, nutrition, coughing, oxygen therapy and use medications
She wanted me to start writing "I assessed/ positioned" and so on.


1a. Although respiratory rate was within a normal range, other respiratory assessments indicate that the patient had difficulty breathing. According to change in rate and depth of respirations, patient experienced less discomfort when sitting up.
1b. No sign of hypoxia or hypoxemia are present.
1c. Although the blood pressure is slightly elevated, it could be a result of hypertension patient was diagnosed with. Other adaptetions have to be assessed to determine if elevated blood pressure is a result of hypoxia.
1d. Patient is afebrile. This could’ve resulted from effects of medications.
1e. Pain is most likely a result of cancer. A tumor was found in the spleen.
2. According to pulse oximetry test, change in positioning and bronchodilators were helpful in improving oxygen saturation. Even tough oxygen saturation in low Fowlers position is low; drop is not significant enough and could be accounted by inaccuracy of pulls oximetry reading
3. Lung sounds indicate that bronchodilators were effective.
4. No change in mental status was noticed. Patient does not show signs of hypoxia
5. Patient had one of the signs of hypoxia, however oxygen saturation was improved by change in positioning and bronchodilators
6. Thick yellow sputum with small amount of blood was expectorated between 9 and 10am. No blood was present later in the day; however sputum remained thick regardless of increased fluid intake. Consistency of sputum indicated that hydration was ineffective, or not enough time was given for changes to occur.
7. Sputum culture determined antimicrobial agent to be used in treatment. RBC, and Hgb are low, therefore oxygen is not delivered to the tissue in sufficient quantities. WBC count is low, possibly as a result of cancer treatment. WBCs are needed to fight the infection, low WBC count indicates that the host is compromised and is unable to fight an infection on her own.
8. Pulse oximetry showed 91% oxygen saturation in the beginning of the day (while in bed with the head of the bed elevated 45º, however changed to 93% while sitting and 94% after receiving bronchodilators.Didn’t obtain Pulse oximetry without oxygen therapy, patient was too short of breath and decreasing oxygen provided to the lungs would place the patient in risk of hypoxia.
9. Started coughing when was repositioned. Stated she felt much better and could breath easier when was sitting in the chair. Fell asleep while in the chair. Stated she couldn’t sleep because it was hard for her to breath in a lower position (low-Fowler.) Oxygen saturation increased from 91 while in bed to 93 while in the chair. Respirations became deeper when the patient was sited.
10. The patient started to cough and expectorated pulmonary secretions after the chest physiotherapy.
11. Patient was deep breathing every hour. Deep breathing resulted in productive cough every time deep breathing was initiated. The patient was also taking deep breaths during auscultation, productive cough resulted.
12. Sputum was thick throughout the time patient was in my care. The patient continued complaining of mouth dryness possibly resulting from mouth breathing. The patient also complained her nares were dry due to use of nasal cannula
13. Patient was fatigued. Had difficulty breathing while talking and coughing, however was able to preserve energy for breathing instead of using it for hygiene and food preparation.
14. Patient reported understanding therapeutic and side effects of Vancomycin. She listed all side effects and therapeutic effects. She also explained the reason to follow doctors orders and take all of the Vancomycin she was prescribed. Unable to establish effectiveness due to time limitations. However if more time was available, I would’ve monitored WBC count, sputum culture results, monitored breathing patterns and cough. No common side effects have been reported. The patient had no signs of allergic reaction to Vancomycin
15. Patient reported understanding of therapeutic and side effects of DuoNeb. She listed all side effects and therapeutic effects Patient reported being able to breathe easier, lung sounds became clear after DuoNeb was administered. Patient complained of dry mouth and was coughing, however both signs were present before the medication was given, therefore could be caused by other stressors.
16. Unable to assess effects due to limited time frame, however if more time was given, I would’ve monitored RBC count. The patient had RBC count of 3.70 on 1/31/08 which is low. RBC are important in oxygen transport. RBC count is not directly related to airway clearance, however the lower RBC count is, the more important airway clearance becomes. No side effects present
17. Patient reported understanding of therapeutic and side effects of Ambien as well as the importance of adequate sleep and proper use of sleep medications. Patient stated she was unable to sleep all night. Stated she was sleeping only 4 hours at night regardless of sleep medication administered before sleep. Patient stated she didn’t experience any side effects of this medication
18. Unable to monitor amount consumed due to time restrains. However patient stated she has a poor appetite.
19. Patient reported understanding and stated she will consume more water, deep breath, eat small frequent meals, and consume energy. Reported understanding of medical treatments prescribed
Goal summary: Goal was partially achieved, patient still had stasis of secretions partially obstructing airflow, however was able to maintain opened airway and removed some of the secretions through coughing. Deep breathing and coughing exercise, chest pt and positioning were helpful in removing the secretions, bronchodilators helped to open the air way by increasing the diameter of bronchioles. Further assessments are needed to evaluate effectiveness of treatments that need more time to be effective. Due to time restrains however, I was unable to assess effectiveness of some of the treatments.


On the last page she listed 5 main changes I had to make.
1. "Col 1 - Need to increase (s) data"
2. "Col 2 - integration of Pt with her specific adaptations (cluster) from col 1. summarize why your pt. is appropriate for your selected N.D."
3. "N.I. - teaching" (I guess she wanted more teaching)
4. "Must assess prior to teaching"
5. "Reassessments have to be done at the end of NCP"


Bibl.
Bibliography
1) “DuoNeb.” Drugs.com. 8 Jan. 2008. 4 Feb. 2008 http://www.drugs.com/duoneb.html.
2) Karch, Amy M. Nursing Drug Guide. Rochester: Lippincott Williams & Wilkins, 2008.
3) Kozier, B., Erb, G., Berman, A., Snyder, S., Fundamentals of Nursing Concepts, Process and Practice, 8th ed., new York, Addison-Wesley, 2008 (a/k/a Prentice Hall)
4) McCance, Kathryn L., and Sue E. Huether. Pathophysiology, the Biologic Basis for Disease in Adults and Children. 3rd ed. St. Louis: Mosby, 1998.
5) Monsom, Kristi, and Arthur Schoenstadt. “Arenesp.” MedTV. 23 Sept. 2007. 5 Feb. 2008 http://cancer.emedtv.com/aranesp/aranesp.html.
6) Pagana, Kathleen D., and Timothy J. Pagana. Mosby's Manual of Diagnostic and Labratory Tests. 2nd ed. St. Louis: Mosby, 2002.
7) Smeltzer, S., Bare, B., et al, Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th ed., Philadelphia, J.B. Lippincott Co., 2008