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Nursing Care Plan for Ineffective Airway Clearance

Nursing Care Plan for Ineffective Airway Clearance

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Published by Juan

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Published by: Juan on Jul 02, 2008
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05/17/2011

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Assessment NursingDiagnosisPlanning Intervention
Long TermShort TermSelectedImplemente
Rationale Evaluation
Subjective:
“Nahihirapansya humingadahil sa plema.” 
asverbalized bythe client’swife.
Objective:
Onendotracheal tubeattachedto amechanical ventilatorwithincreasingduration of  T-pieceweaning(5, 15, 30,45, 60mins.)Ineffectiveairwayclearancerelated toincreasedproduction of bronchialsecretionssecondary tofluid shift toextravascularcompartment.During theclient’s stayat thehospital hewill be able tomaintainpatent airwayas evidencedby:
Independence fromoxygenandventilatorysupport
Normalrespirationasevidencedbyabsence of dyspneaandadventitioFollowing an8-hr nursingintervention,the client willbe able to:
Achievesuccessfulprogressive T-pieceweaning of (5-15-30-45-60mins)
Sustainrespiratoryrate withinnormalrange: RR-12-20cpm.
Displaydecreasing
Assessrespiratoryfunction,e.g.,breathsounds,rate, anduse oaccessorymusclesandsecretioncharacteristics andamount.
Assessedrespiratoryrate.
Notedchestmovement; use oaccessorymusclesduringrespiration.
Auscultated breathsounds;notedareas withpresence
Provides abasis forevaluatingadequacyof ventilation.
Use oaccessorymuscles of respirationmay occurinresponsetoineffectiveventilation.
CracklesindicateAt the end of the shift, theclient wasable todisplaypatency oairway asmanifestedby:
Successful T-pieceweaningbyachievingthe goal of completing60mins.
Client’srespiratoryrate iswithinnormalrange: RR-
 
Assessment NursingDiagnosisPlanning Intervention
Long TermShort TermSelectedImplemente
Rationale Evaluation
Abnormalbreathsounds:wetcrackleson (R) and(L) lungbases.
Dyspnea;use oaccessorymusclesforrespiration: elevatedshoulders.
Increase inrespiratoryrate: RR-25 cpmus breathsounds(wetcrackles).
Normalbreathingpattern:RR = 12-20 cpm
Absence of bronchialsecretions
Normalchest x-ray results
Allayrestless-nessamount of secretions(less than40cc).
Allayrestless-ness.
Positionpatient insemi- orhigh-Fowler’sposition.
Assessairwaypatency.
Suction asneededwhenpatient isof adventitious sounds.
Documentedrespiratorysecretions:characterandamount of sputum.
Maintainedpatient onmoderatehigh backrest.
Checkedforobstructioaccumulation osecretionsandinability toclearairways.
Expectorations maybedifferentwhensecretionsare verythick.
Positioninghelpsmaximizelungexpansion.18 bpm.
Secretionsdecreasedin amountfrom 40 ccto 30 cccollectedin an 8-hrshift(Continueassessment of respiratorystatus andsuctioningasneeded).
Client’srestlessness wasalleviated
 
Assessment NursingDiagnosisPlanning Intervention
Long TermShort TermSelectedImplemente
Rationale Evaluation
Secretioncharacteristics:yellowishin colorand 40 mlin amountcollectedin an 8-hrshift.
Chest x-ray reportshazinesson bothlowerhemithorax taken onSeptember 7, 2006.
Restlessexperiencingdifficultyof breathing,limitingduration of suction to15 sec orless.
Administermedications asindicated:Bronchodilators.ns:accumulation osecretions.
Suctionedpatientlimited to5-secduration.
 Tomaintainadequateairwaypatency.
Durationshould belimited toreducehazard of hypoxia,damageairwaymucosaand impairciliaaction.
Increaseslumen sizeandremainedcalm.

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