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Ineffective Airway Clearance

Ineffective Airway Clearance



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Published by DarkCeades
Nursing care plan
Nursing care plan

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Categories:Types, School Work
Published by: DarkCeades on Feb 06, 2009
Copyright:Attribution Non-commercial


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CuesNursingDiagnosisAnalysisGoal andObjectivesInterventionsRationaleEvaluationSubjective:
- The clientverbalized,“Nahihiripantalaga akohuminga lalo nanung una kongpunta dito sahospital”-“1 bottle langnauubas kongtubig sa isangaraw”
- AdventitiousBreath Sounds(Rales)-Cough withphlegm-PaleIneffectiveAirwayClearancerelated toSecretions inthe bronchiIncreasedamount andviscosity of secretionsand/or inabilityto clearsecretionsthrough thenormal coughmechanismmay lead topooling of secretions inlower airways.Pooling of secretions leadsto infection andinadequate gasexchange.(p229,Nettina,Manualof nursingpractice)
After an8-hour shift,the client’ssecretionswould belessened.
1. After 30minutes, theclient will beable to expelmucous by:a.Doingpropercoughingtechniqueb.ApplyingChestpercussionDEVELOPMENTALa. Teach theclient propercoughingtechnique.SUPPLEMENTALb.Apply ChestPercussion tothe Client. The patient needs tocough to be able toremove the mucus(p530,Smeltzer,Medical-surgical Nursing vol.1)Chest physiotherapyis important inloosening andmobilizingsecretions.Indications for chestphysiotherapyinclude sputumretention notresponsive tospontaneous ordirected cough,abnormal chest x-rayGoal met.1. The clientwas able toexpel mucous.
c.ChestDrainaged.Administration of drugs2. The clientwill be able tomaintainadequatehydration by:a.Increasingoral fluidintakeb.RegulatingintravenouSUPPLEMENTALc. Position theclient forPosturalDrainage.FACILITATIVEd. AdministerAntibiotics asorderedSUPPLEMENTALa. Increase thenumber of fluidbeing drunk bythe patient.SUPPLEMENTALb. Regulate theIV fluid asordered.findings consistentwith infiltrates ordeterioration inoxygentaion. (p530,Smeltzer,Medical-surgical Nursing vol.1) The patient is placedin the properposition to drain theinvolved lungsegments. (p530,Smeltzer,Medical-surgical Nursing vol.1)For infections.(NANDA)An increasedrespiratory rateleads to an increasein insensible fluidloss duringexhalation and canlead to dehydration.(p530,Smeltzer,Medical-surgical Nursing vol.1)2. The clientwas able tomaintainadequatehydration.Efficiency The time,materials, andhumanresources wereusedeconomicallyAdequacy The numbers of interventionswere sufficient.

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