DAILY CLINICAL PREPARATION: OVERVIEW, Exams of Clinical Psychology

Download DAILY CLINICAL PREPARATION: OVERVIEW and more Exams Clinical Psychology in PDF only on Docsity! RNSG 2162 Fall 2015/Spring 2016 Page 1 DAILY CLINICAL PREPARATION: OVERVIEW NOTE: This sheet must be updated (if applicable) in different color ink for 2nd day of care. Student: Adriana Marrufo Date(s) of Care: 9.26.15 Client Initials/Age/Gender/Room #: M.L., 88, F, Rm#17 Date Admitted: 9.23.15 Diagnosis (on admission, and current): Code Ice (cardiac arrest), anoxic brain injury Allergies: NKDA Height 152cm = 60in Weight: 60kg = 132lbs Diet: NPO I and O: 9.24.15: I: 3,578, O: 950, 9.25.15: I: O: Activity: Bed rest Vital Signs: 9.25.15 @ 1530: HR = 134, BP = 114/ 48, SpO2 = 99% Therapies (respiratory, physical, etc.): Respiratory tx BID w/ Brovana Intravenous solutions: Propofol @ 20mcg/kg/min, 100mL Drains and other tubes (include location): Foley catheter 16F, ETT Special equipment: Vent: ETT: 8 @ cm, AC rate:18, TV:500, FiO2: 110%, PEEP: 12 _____________________________________________________________________________ _ Special Nursing Treatments (e.g.., dressing changes, bedside blood sugars, etc.): _____________ CVC dressing change Code Status: DNR Restraints: None present or ordered Date & order: N/A Daily Fluid Requirements: ______________________________Actual____________________ Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 2 Daily kcal requirements:________________________________Actual____________________ Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 5 the pt. at least Q2H during the day. The nurse also implements measures to relieve anxiety and agitation if applicable and possible. The most important priority is to assess oxygenation status and provide suctioning PRN and oral care daily. 11. What is the primary teaching/learning topic for the client? Because the pt has a history of COPD which is known to cause respiratory failure, her primary teaching goal is to avoid factors that might cause an exacerbation, such as smoking, being around large amounts of dust, and harmful chemicals. 12. What are the discharge goals for this client? The discharge goals include: Absence of signs and s/s of respiratory failure and no evidence of respiratory failure on laboratory tests. Normal respiratory pattern. Maintains normal ABG/pulse oximetry or returns to baseline values. Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 6 Students Name: Adriana Marrufo Client Initials: M.L. Date: 9.25.15 Any abnormal laboratory results for this client that are directly related to the admitting medical diagnosis. Include any abnormal results obtained within the past three days, plus on the days you care for the client: Test Referenc e Ranges Client Results And date(s) done Why this result is abnormal in relationship to the client’s adm. med. Dx What you need to do or watch for secondary to the abnormal result. Cl 95-105 9-23-15: 109(H) 9-24-15: 117(H) 9-25-15: 115(H) 9-26-15: Cardiac decompensation is known to increase levels. The pt. has CAD which can cause decompensation. Assess for s/s symptoms of hyperchloremia: weakness, lethargy, and deep, rapid, vigorous breathing. CO2 22-30 9-23-15: 14(L) 9-24-15: 15(L) 9-25-15: 15(L) 9-26-15: The pt. has COPD which is known to increase CO2 levels due to damaged alveoli. Check for s/s of metabolic alkalosis: shallow breathing, hand tremor, numbness or tingling in the face, hands, and feet. Anion 10-17 9-23-15: 17(H) 9-24-15: 9 9-25-15: 9 9-26-15: A high level of sodium causes low levels of anion. The pts sodium level is in the high range. Check for s/s of metabolic alkalosis: shallow breathing, hand tremor, numbness or tingling in the face, hands, and feet. Gluc 9-23-15: 293(H) 9-24-15: 291(H) 9-25-15: 139 9-26-15: The pt. has diabetes mellitus which decreases insulin levels and thus glucose is not properly utilized and levels increase. Watch for s/s of hyperglycemia: polyphasia, polyuria, polydipsia, blurred vision, fatigue, fruit smelling breath, dry mouth -Administer insulin as prescribed BUN 5-25 9-23-15: 14 9-24-15: 18 9-25-15: 24(H) The pt. has DM and CHF both of which are known to increase the Report urinary output less than 25 ml/hr or 600 ml/day. With Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 7 9-26-15: BUN due to the fact that there is poor renal perfusion and minimizing the amount of urea excreted. decreased urine output, urea accumulates in the blood. Calcium 9-11 9-23-15: 9.9 9-24-15: 7.7(L) 9-25-15: 8.4(L) 9-26-15: Infections can lower the total count. The pt. was admitted with sepsis. Assess for s/s of hypocalcemia: tetany, muscular twitching and tremors, spasm of the larynx. Phosphate 9-23-15: 9-24-15: 1.6(L) 9-25-15: 3.4(L) 9-26-15: Magnesium 9-23-15: 2.7(H) 9-24-15: 1.7(H) 9-25-15: 2.0(H) 9-26-15: Albumin 3.5 – 5.0 9-23-15: 2.9(L) 9-24-15: 2.6(L) 9-25-15: 2.1(L) 9-26-15: The pt. has congestive heart failure which can lower albumin levels. Assess for peripheral edema in the lower extremities. A/G RA 3.5 – 5.0 9-23-15: 0.8(L) 9-24-15: 0.7(L) 9-25-15: 0.6(L) 9-26-15: The pt. has congestive heart failure which can lower albumin levels and lower the gap ratio. Check for peripheral edema and ascites. A low level decreases oncotic pressure shifting fluids from vascular to tissue spaces. TP 9-23-15: 6.5 9-24-15: 6.2(L) 9-25-15: 5.8(L) 9-26-15: Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 10 Monophils 9-23-15: 3.8(L) 9-24-15: 9-25-15: 7.7 9-26-15: Basophils 9-23-15: 0.2 9-24-15: 9-25-15: 0.0(L) 9-26-15: PT 10-13 9-23-15: 17.6(H) 9-24-15: 9-25-15: 9-26-15: Coumadin interferes with the pt’s clotting factors therefore increasing the PT time. Observe the pt for s/s of bleeding: purpura, hematuria, hematemesis, and nosebleeds. PCO2 9-23-15: 54(H) 9-24-15: 32(L) 9-25-15: 21(L) 9-26-15: TCO2 9-23-15: 11.8(L) 9-24-15: 10.9(L) 9-25-15: 11.9(L) 9-26-15: HCO3 24-28 9-23-15: 10.1(L) 9-24-15: 9.9(L) 9-25-15: 11.3(L) 9-26-15: The use of diuretics (Lasix) allows excessive wasting of both hydrogen and potassium ions causing the PH to increase. Assess for s/s of metabolic alkalosis: shallow breathing, vomiting. Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 11 Students Name: Adriana Marrufo Client Initials: D.M.C. Date: 9.18.15 Any abnormal diagnostic results (e.g., x-rays, ekg, MRI, endoscopy, cardiac catherization, etc)… for this client that are directly related to the admitting medical diagnosis. Include any abnormal results obtained within the past three days, plus on the days you care for the client: Test Client Results And date(s) done Why this result is abnormal in relationship to the client’s adm. med. Dx What you need to do or watch for secondary to the abnormal result. x-ray (chest) x-ray (chest) x-ray (chest) Rt. upper lobe infiltrates, bilateral pleural effusion > on Lt. 9.10.15 Lt. pleural effusion. Rt. upper lobe infiltrates, Rt. pleural effusion. 9.11.15 Mild CHF, no pneumothorax 9.12.15 As the air sacs fill with fluid this reduces the lung’s ability to collect and distribute oxygen to the cells. The lungs become stiff and difficult to ventilate. This could have been the cause that lead the pt. to experience respiratory failure. The presence of pleural effusion is frequently found in pts with CHF. - Monitor rate, rhythm, and effort of respirations. - Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds. - Monitor pt.’s respiratory secretions. CT brain scan w/o contrast W/o moderate atrophy w/ ischemic 9.10.15 This result might confirm that the pt. experienced a TIA, a condition she has a history of. - Assess for s/s such as: loss of vision, confusion, speech problems, weakness or numbness of the face/arm/leg, nose bleed. Ultrasound of abd Bilateral renal atrophy, no cholelithiasis 9.11.15 The pt has CHF, HTN, and stenosis which can alter the blood supply to the kidneys and cause damage - Assess daily urine output. - Report urinary output less than 25 ml/hr or 600 ml/day which may signify renal damage. Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 12 Students Name: Adriana Marrufo Client Initials: M.L. Date: 9.26.15 Medications the client is receiving that are directly related to the admitting medical diagnosis. If you elect to submit drug cards, you must still fill out columns B and C. A Drug name (generic & trade) and class B Client’s dose, route, frequency C Rationale for how drug benefits pt. D Comprehensive nursing considerations propofol Diprivan general anesthetic 10mg IV titrate PRN For the induction and maintenance of anesthesia/sedation of intubated, mechanically ventilated patients. - Assess respiratory status, pulse, and BP continuously. - Assess level of sedation and LOC throughout and following administration. - Wake-up and assessment of CNS function should be done daily - Monitor for propofol infusion syndrome (severe metabolic acidosis, hyperkalemia, lipemia, rhabdomyolysis, hepatomegaly, cardiac and renal failure). - If hypotension occurs, treatment includes IV fluids, repositioning, and vasopressors. ceftriaxone Rocephin 3rd generation cephalosporin 1gm IV push over 3-5min daily @ 0900 Binds to bacterial cell wall membrane, causing cell death. Has a bactericidal action against susceptible bacteria. *Pt. had an elevated WBC count, which may indicate infection. - Assess for infection (vital signs; WBC count). - Determine previous use of and reactions to penicillins or cephalosporins. - Observe patient for s/s of anaphylaxis. - Monitor injection site frequently for phlebitis (pain, redness, swelling). Change sites every 48–72 hr to prevent phlebitis. pantoprazole Protonix proton pump inhibitor 40mg IV push over at least 2min daily @ 0900 Binds to an enzyme in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen. Diminishes accumulation of acid in the gastric - Assess patient routinely for epigastric or abd pain and for frank or occult blood in stool, emesis, or gastric aspirate. - May cause hypomagnesemia. Monitor serum magnesium. Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 15 decrease the incidence and severity of seizures. potassium chloride mineral and electrolyte replacements/ supplements PO 20mEq for K+ 3.4-3.6 40mEq for K+ 3.0-3.39 PRN Maintains acid- base balance, isotonicity, and electrophysiologic balance of the cell. For tx and prevention of K+ depletions - Assess for s/s of hypokalemia (weakness, fatigue, U wave on ECG, arrhythmias, polyuria, polydipsia) and hyperkalemia. - Monitor serum potassium before and periodically during therapy. Monitor renal function, serum bicarbonate, and pH. Determine serum magnesium level if patient has refractory hypokalemia; hypomagnesemia should be corrected to facilitate effectiveness of potassium replacement. Monitor serum chloride because hypochloremia may occur if replacing potassium without concurrent chloride. - Symptoms of toxicity are those of hyperkalemia (slow, irregular heartbeat; fatigue; muscle weakness; paresthesia; confusion; dyspnea; peaked T waves; depressed ST segments; prolonged QT segments; widened QRS complexes; loss of P waves; and cardiac arrhythmias). Treatment includes discontinuation of potassium, administration of sodium bicarbonate to correct acidosis, dextrose and insulin to facilitate passage of potassium into cells, calcium salts to reverse ECG effects (in patients who are not receiving digoxin), sodium polystyrene used as an exchange resin, and/or dialysis for patient with impaired renal function. enoxaparin Lovenox antithrombotics/ low molecular weight heparins 30mg subQ daily @ 0600 Potentiates the inhibitory effect of antithrombin on factor Xa and thrombim for the prevention of VTE. - Assess for signs of bleeding and hemorrhage (bleeding gums; nosebleed; unusual bruising; black, tarry stools; hematuria; fall in hematocrit or BP; guaiac-positive stools); bleeding from surgical site. Notify health care professional if these occur. - For overdose, protamine sulfate 1 mg for each mg of enoxaparin should be administered by slow IV injection. mupirocin Bactroban anti-infective 1 application nasal 2x/day @ 1000, 2200 Inhibits bacterial protein synthesis to inhibit bacterial growth and reproduction. - Assess any present lesions before and daily during therapy. Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 16 PHYSICAL ASSESSMENT FLOWSHEET Students Name: Adriana Marrufo Instructor’s Initials: E.R Room # 17 Date: 9-26-15 Note: Please use a different color ink for each day - use checkmarks only, whenever possible. Cardiovascular Day 1 Day 2 1. Apical heart rate 0800 = 76 bpm 1200 = 74bpm 0800 = 66bpm 1200 = 80bpm 2. Apical rhythm Regular Irregular X Regular X Irregular 3. Heart sounds S1 X S2 X List other (eg, S3, murmurs, etc.) S1 X S2 X List other (eg, S3, murmurs, etc.) 4. Blood pressure 0800 = 139/64 mmHg 1200 = 142/68 mmHg 0800 = 131/57 mmHg 1200 = 151/67 mmHg 5. Peripheral pulses [ 0 = not palpable 1 = weak 2 = normal 3 = bounding 4 = present only with doppler... not necessary to put rate, just volume carotid RT 2 LT 2 º carotid RT 2 LT 2 ºbrachial 2 2 º brachial 2 2 ºradial 2 2 º radial 2 2 º posterior tibialis 0 0 º posterior tibialis 0 0 ºpedal 0 0 º pedal 0 0 6. Capillary refill (put # of seconds) ºfingers RT <3secs LT <3secs º fingers RT <3secs LT <3secs º toes <3secs <3secs º toes <3secs <3secs 7. Edema (specify site and if pitting or non-pitting Hands, Lt. +4, Rt. +2 Hands, Lt. +1, Rt. +2 List any other relevant/abnormal findings Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 17 Respiratory Day 1 Day 2 1. Rate 0800 = 11bpm 1200 = 16bpm 0800 = 18bpm 1200 = 30bpm 2. Rhythm Regular X Irregular Regular X Irregular 3. Depth Normal X Shallow Labored Normal X Shallow Labored 4. Breath Sounds º RT Clear X Wheezes Crackles º RT Clear Wheezes Crackles X Diminished Absent Diminished Absent º LT Clear X Wheezes Crackles º LT Clear Wheezes Crackles X Diminished Absent Diminished Absent 5. Cough (if yes, state if productive or unproductive; nature of any sputum.) No cough present. No cough present. CNS 1. Level of consciousness (spon. = spontaneously) º eyes Open spon Open to speech º eyes Open spon Open to speech X Open to pain X Don’t open Open to pain Don’t open º verbal response Oriented Confused º verbal response Oriented Confused Inappropriate Words Incomprehensible Sounds Inappropriate Words Incomprehensible Sounds None X None X Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 20 Reproductive Day 1 Day 2 Describe any reproductive abnormalities Integumentary 1. Overall temperature of skin Warm Hot Cool X Cold Warm X Hot Cool Cold 2. Overall hydration of skin. Resilient turgor X Poor turgor Resilient turgor X Poor turgor 3. Incisions (if yes, describe and give location) None noted. None noted. 4. Pressure ulcers and/or other wounds (if yes, describe and give location) None noted. None noted. 5. Drains (if yes, include nature of drainage) JP Hemovac Wound Vac T-tube Other (describe) JP Hemovac Woun d Vac T-tube Other (describe) 6. IV access (if yes, state site, type, appearance) PICC, Rt. neck, no drainage, redness, or swelling, warm to touch. PICC, Rt. neck, no drainage, redness, or swelling, warm to touch. 7. List any other relevant/abnormal findings. Rt. supraclavicular laceration about 2 1/2 cm in length. No drainage noted. Rt. supraclavicular laceration about 2 1/2 cm in length. No drainage noted. Endocrine Bedside Blood Sugars Time = Time = Other Time = Time = Other times Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 21 Student Name: Adriana Marrufo Client Initials: D.M.C. PSYCHOLOGICAL - SOCIOLOGICAL - CULTURAL - COMMUNICATION ASSESSMENT Psychological- (include reaction to illness, reaction to hospitalization and reaction to care). Unable to answer because pt. was disoriented and family not present to answer for her. _____________________________________________________________________________ _ _____________________________________________________________________________ _ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____ Sociological (include spouse or significant other(s), children, living arrangements, education, past and current employment, finances): Unable to answer because pt. was disoriented and family not present to answer for her. _____________________________________________________________________________ _ _____________________________________________________________________________ _ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____ Cultural/Religious Beliefs Related to Health and Health Care: Unable to answer because pt. was disoriented and family not present to answer for her. _____________________________________________________________________________ _ _____________________________________________________________________________ _ Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 22 _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ______ Communicating Assessment of Communication Verbal (include language, grammar, vocabulary, use of slang, stuttering, etc., whether initiates conversation Unable to answer because pt. was disoriented and did not speak throughout my shift. _____________________________________________________________________________ _ Nonverbal (physical appearance, facial expressions, gestures, posture, other) Pt. was usually sedated, and when on “sedation vacation”, she would lie calm and open her eyes in response to sound.. _____________________________________________________________________________ _ Interaction with family members (phone, visits) and staff Unable to answer because pt. was disoriented and unable to interact w/ family and/or staff. _____________________________________________________________________________ _ Developmental Select the applicable developmental task: _______ intimacy vs. isolation _______ generativity vs. stagnation X integrity vs. despair Developmental Task (identify the client’s major developmental task [according to Erikson] and give specific evidence to support why you believe client has/has not positively resolved task): 1. Intimacy vs. Isolation ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. Generativity vs. Stagnation Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 25 09/26/2015 0950 Assisted RN Jared in turning pt. onto Rt. side. ------------------------------------------------------------------------------------------------------------------- Adriana Marrufo, SN, EPCC 09/26/2015 1000 Medications administered. PICC line on Rt. side of neck free of manifestations of infection/infiltration/phlebitis w/ positive blood return. Flushed with 10mL NaCl. Ceftriaxone, 1gm/10mL NaCl, IV push, over 3min. Pantoprazole, 40mg/10mL NaCl, also IV push, over 5min. 20 u of insulin detemir administered into subQ tissue of Rt. upper arm. Carvedilol 3.125mg, crushed, mixed with tap water, and given via OGT after proper placement of OGT established. ------------------------------------------------------- Adriana Marrufo, SN, EPCC 09/26/2015 1100 Performed oral suction w/ Yankauer suction tube. No pt. discomfort noted. Performed oral care using SAGE QCare oral care kit. Pt. tolerated both suction and oral care well. SpO2 remained 98-99% throughout. ------------------------------ Adriana Marrufo, SN, EPCC 09/26/2015 1150 Assisted RN Jared in turning pt. onto Lt. side. ------------------------------------------------------------------------------------------------------------------- Adriana Marrufo, SN, EPCC 09/26/2015 1200 Pt.’s bedside blood glucose taken, result of 213. 12u of insulin aspart administered into subQ tissue of Lt. upper arm. Pt.’s VS noted = HR: 74, BP: 142/68, RR: 16, and Temp: 98.6F. ---------------------------------------------------------- Adriana Marrufo, SN, EPCC 09/26/2015 1300 Performed oral care using SAGE QCare oral care kit. Pt. tolerated procedure well. SpO2 remained 98-99% throughout. ----------------- Adriana Marrufo, SN, EPCC 09/26/2015 1330 Changed CVC dressing using sterile technique. Assessed site for redness, swelling, discharge. None noted. Cleansed skin around site with alcohol and iodine, applied new biopatch and new dressing, noting date, time, and initials. ----------- Adriana Marrufo, SN, EPCC 09/26/2015 1345 Assisted RN Jared in turning pt. onto Rt. side. ------------------------------------------------------------------------------------------------------------------- Adriana Marrufo, SN, EPCC 09/26/2015 1400 Performed oral suction w/ Yankauer suction tube. No pt. discomfort noted. SpO2 remained 98-99% throughout. ------------------------------------ Adriana Marrufo, SN, EPCC Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 26 09/26/2015 1500 Performed oral care using SAGE QCare oral care kit. Pt. tolerated procedure well. SpO2 remained 98-99% throughout. ----------------- Adriana Marrufo, SN, EPCC 09/26/2015 1630 Reported off to RN Jared. Pt. stable, lying in bed, 0 pain indicated via facial expressions. --------------------------------------------------------- Adriana Marrufo, SN, EPCC Zip 16/2162 Packet RNSG 2162 Fall 2015/Spring 2016 Page 27 Client initials: D.M.C Student name Adriana Marrufo Date: 9.20.15 NURSING CARE PLAN ANALYSIS PLANNING AND IMPLEMENTATION Nursing Diagnosis Priority Pt. Goal –E.O.’s Nursing Orders Rationale for Nursing Orders Dysfunctional weaning response R/T 2 failed weaning attempts AMB -metabolic alkalosis: ABGs: pH.=7.48 HCO3=41.7 -Tidal volume range of low to mid 200s. -Abnormal respiratory rate: 30bpm@1200 -Ronchi heard upon auscultation and increased oral secretions visible upon inspection. High Priority According to Maslow’s Hierarchy of Needs, anything that affects an individual physically should be addressed first. Also, using the ABC prioritization technique, any problem with the airway is of highest concern due to the fact that lack of oxygen can lead to greater damages and even death. Date written 9.20.15 The pt will achieve progressive weaning goals. AEB: The pt. will… E.O.No1: Actively participate when weaning is attempted. E.O.No2: Reestablish independent respirations w/ ABG’s w/in acceptable range (pH= 7.35-7.45, HCO3=24-28). E.O.No3: Achieve VT w/in acceptable range of at least 400mL on inspiration. 9.21.15, 1600 The nurse will: N.O.No1: Remove secretions PRN via suctioning throughout shift. N.O.No2: Position pt. to optimize oxygenation by ensuring HOB is elevated at least 30° throughout shift. N.O.No3: Assist pt. in taking control of breathing (instructing pt. to take deep breaths) if weaning is attempted or ventilatory support is interrupted during a procedure or activity throughout shift. N.O.No4: Monitor ET tube placement. Note lip line marking and compare with desired placement (22 cm) during physical assessment at start of shift, and whenever suctioning or performing oral care throughout shift. N.O.No5: Note excessive coughing, increased dyspnea, high-pressure alarm sounding on ventilator, visible secretions in endotracheal tube, and increased rhonchi during physical assessment. Adriana Marrufo, SN-EPCC, 9.20.15 @ 2000 1. A tube partially obstructed with secretions increases resistance to flow, which increases the work of breathing. (Carpenitto, Pg. 723) 2. Maintaining head of bed elevated 30 degrees reduces the risk of aspiration. (Carpenitto, Pg. 723) 3. Coaching client to take slower, deeper breaths; practice abdominal or pursed-lip breathing; assume position of comfort; and use relaxation techniques can be helpful in maximizing respiratory function. (Doenges, Pg. 178) 4. The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax. (Doenges, Pg. 178) 5. The intubated client often has an ineffective cough reflex, or client may have neuromuscular or neurosensory impairment, altering ability to cough. Client is usually dependent on suctioning to remove secretions. (Doenges, Pg. 184) Zip 16/2162 Packet