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26492499 Ineffective Airway Clearance

26492499 Ineffective Airway Clearance

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Published by: Jaivie Dela Peña Cabrera on Jul 10, 2010
Copyright:Attribution Non-commercial

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07/24/2010

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CUES NURSINGDIAGNOSISRATIONALE PLANNING NURSINGINTERVETIONRATIONALE EVALUATION
SUBJECTIVE:“Nahihirapan nasiya humingadahil sa plemahindi niyamailabas, grabe nakasi ang ubo niyaneh”
OBJECTIVES:>DOB>Orthopnea>Wheezes on both lung fields>uses intercostalmuscles uponrespiration>ProductiveCoughIneffectiveAirwayClearance related toretainedsecretions in the bronchisecondary to pneumonia Normally thelungs are freefrom secretions.Pneumonia bacteria areinvading thelung parenchymathus, producinginflammatory process. Andthese responsesleading to fillingof the alveolar sacs withexudates leadingto consolidation.The airway isnarrowed thuswheezes is beingheard. DOB insome casesorthopnea isobserved.Short term:After 1 hour of nursingintervention, theclient will beable to maintainairway patency,clear breathsounds.Long Term:After 1 day of nursingintervention, theclient will beable toexpectorateretainedsecretions andmaintain normal breathing pattern.> establishrapport> monitor VS> suctionsecretions PRN> place onorthopneic position> Elevate HOB> Encouragedeep breathing> give bronchodilator asordered> refer for anyabnormalchanges in the body.> to gainclient’s andrelatives trust> to obtain baseline data> to decreasesecretionretained in the bronchi>to maintain patent airway>to takeadvantage of thegravity decrease pressure on thediaphragm.> to mobilizesecretion> to moistensecretions for easyexpectoration> to medicallymanage anycomplications.The client shallhave maintainedairway patency,clear breathsounds(goal partiallymet)The client shallhaveexpectoratedretainedsecretions andmaintainednormal breathing pattern(goal met)

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