Nursing Care Plan

Ineffective airway clearance

Cues Nursing Planning Intervention Rationale Evaluation
Diagnosis
I- “nahihirapan Ineffective After nursing To maintain Goes met the
ako huminga airway intervention the adequate patient client able to
at kapag clearance patient will able to airway the nurse maintain
umuubo ako related to Objectives: manage will able: airway
may asthma as a and maintain a. monitor Indicative of clearance and
kasamang manifested by airway patency. respiration respiratory clear
plema” as difficulty of After 2hrs. nursing & breath distress or secretions
verbalized by breathing. intervention the sound, accumulation readily.
the patient. patient will: noting rate of secretion.
a. Verbalize & sounds
O- Difficulty & understandin (e.g.
rapidly in g of causes & tachypnea,
breathing. therapeutic crackles,
management wheezes.)
M- RR-23 bpm regimen b. Elevate
BP-100/70 within head of To take
PR-82 bpm 20mins. bed/change advantage of
T- 37.3 b. Demonstrate position gravity
behavior to every 2hrs. decreasing,
improve & prn. pressure on
maintain the diaphragm
clear airway & enhancing
within c. Keep drainage of
30mins. environment ventilation to
c. Demonstrate allergen free diff. lung
reduction of (e.g.broncho segment.
congestion w/ scopy
breath tracheotomy To clear/
sounds clear ) maintain open
 respiration d. To mobilize airway.
noiseless secretion
improved  encourage
oxygen deep
exchange breathing &
within coughing
30mins. exercise
d. Identify splint
potential chest/incisio To maximize
complication n. effort.
on how to  Dependent;
initiate administer
appropriate analgesic
preventive or  Give
corrective expectorant
actions within s or
20mins. bronchodilat
ors as To improve
ordered. cough when
 To promote pain is
wellness; inhibiting
demonstrate effort.
client in
performing
specific
airway
clearance
technique.
Cues Nursing Planning or Nursing Rationale Evaluation
Diagnosis Goal Intervention
I: “My incision •Acute pain •After 2 hrs nursing •Use pain rating •To evaluate •Goals
site is so related to intervention the scale appropriate patient partially met.
painful” as physical patient will: for age/cognition response to The patient
verbalize by factor e.g., pain. able to control
the patient. disruption of •Decrease pain •Observe and reduce
skin & tissue rate from 5 to 2 nonverbal pain.
O: Presence of (incision) as cues/pain •Observations
facial grimace evidence by •Report pain is behaviors. may/may not •From pain
when reports of relieved/controlled. be congruent rate of 5
palpation the pain and with verbal decrease to 3.
abdominal guarding at reports or may
area and the area. be only
guarding the indicator
area when present when
assessing it. •Encourage patient is
adequate rest unable to
M: periods. verbalize.
•BP- 100/70
mmhg •To prevent
•T- 37.3°C fatigue.
•PR- 89 bpm
•RR- 19
•Pain scale-
5/10