1. Use Standard Protocol.
2. Correct positioning of client:
1. Assess for possible impairment of airway clearance: increased work of breathing or inability to clear copious or tenacious secretions by coughing.
2. Observe for signs of airway obstruction.
3. Assess client's baseline knowledge of positioning, CPAP/BiPAP, and PEFR.
4. Review physician's order for CPAP/BiPAP and predicted values for PEFR.
Semi-Fowler's or high Fowler's, sitting on side of bed, or in chair with elbows resting on knees. Clients with COPD may benefit from leaning over table with arms propped up.
When client who is ambulating experiences shortness of breath or the need to cough, encourage a position that supports client.
Determine if two pillows or flat is more comfortable for client. Turn at least every 2 hours to encourage secretion drainage. Consider maneuvers to drain areas of lungs with retained secretions by gravity if tolerated by client. If unilateral reexpansion is needed, have client lie with side requiring expansion up: "good side down, affected lung up."
3. Controlled coughing
Place client in upright position. High Fowler's leaning forward, or with knees bent and a small pillow or hand to support the abdomen may augment expiratory pressure.
Instruct client to take two slow, deep breaths, inhaling through the nose and exhaling out the mouth.
Instruct client to inhale deeply a third time, hold this breath, and count to three; then cough deeply for two or three consecutive coughs without inhaling between coughs.
Instruct the client to push air forcefully out of the lungs.
4. Apply CPAP/BiPAP:
Position face mask or nasal mask tightly and adjust head strap until seal is maintained and client is able to tolerate.
Instruct client to breathe normally.
Apply at ordered setting for prescribed length of time.
5. Obtain PEFR measurements:
Instruct client about purpose and rationale.
Place client in an upright position.
Slide indicator to base of the numbered scale.
Instruct client to take a deep breath.
Have client place meter mouthpiece in the mouth and close lips, making a firm seal.
Have client blow out as hard and fast as possible through the mouth only.
This maneuver should be repeated two additional times, with the highest number recorded.
If client is to record PEFR at home, have client demonstrate PEFR technique independently and assess ability to record PEFR accurately in a diary.
6. Use Completion Protocol.
1. Observe client's body alignment and position whenever in visual contact with client. Reposition as needed, at least every 2 hours.
2. Monitor client's respiratory status. Auscultate lung sounds at least q8h.
3. Assess breathing during sleep with CPAP.
4. Monitor ABGs/pulse oximetry.
5. Observe technique of client/family using equipment.
6. Identify Unexpected Outcomes and Nursing Interventions
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