List of problems and interventions for Essay Case Option 2 – the adult case Problem 1: Ineffective Airway Clearance Nursing Interventions Auscultate breath sounds. The nurse should note adventitious breath sounds such as crackles, wheezes and rhonchi. Rationale for this intervention: some level of bronchospasm is present with obstructions within the airway and might or might not be manifested with adventitious sounds (Avsar, 2011). Evaluate or monitor the respiratory rate. The nurse should note the inspiratory/expiratory ratio. Rationale for this intervention: Tachypnia is commonly present to some extent and might be pronounced on admission or during stress or concurrent acute infectious process. Reduce environmental pollution, for instance by minimizing smoke and dust. Rationale. Dust and smoke are precipitators of allergic type respiratory reactions that could aggravate or set off onset of acute episode (Vijayan, 2013). Problem 2: Impaired Gas Exchange Nursing Interventions Evaluate respiratory depth and rate. The nurse should note the use of accessory muscles, inability to converse or speak, and pursed-lip breathing. Rationale: this intervention is important in assessing the extent of respiratory distress and/or chronicity of the illness process (Stone et al., 2014).
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