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Nursing Care plan for case presentation Cues Nursing Diagnosis Background knowledge Short term Plan

Ineffective airway clearance Long term Plan Intervention Rationale Expected outcome

Independent: S: O: >Coherent, alert and fully awake >(+) Pale conjunctiva >(+) Pale oral mucous membrane >Episode of non productive cough noted >Appears weak >With wheezes on bilateral lower lobes noted upon auscultation
>presence of nasal watery discharge

Ineffective airway clearance R/T

presence of thick mucus secretions in tracheo bronchial tree.

Entry of virus and bacteria and allergens through inspiration l v Activation of defense mechanism l V Loss of effectiveness of defense mechanism l v Penetrate the sterile lower respiratory tract (lungs) l v alveoli l v

Within 4hours of nursing intervention, the patient will manage to maintain a patent airway

After one week of nursing intervention, the patient will manifest decrease of secretions in a i r w a y and effective breathing,

Short term: 1.) Place patient into high fowlers position maximize lung expansion and decrease respiratory effort After almost 8 hours of Nursing Interventions, the patient: 1.Manifest stable and normal vital signs (BP, RR, PR, Temp) 2. Manifest clear breath sounds as manifested by absence of wheezes 3.Cough effectively through capability to expectorate all accumulated secretions 4. Adhere and comply to all therapeutic regimens like medications

2.) Advise mother to helps to do manually loosen back tapping or dislodge secretions

3.) Teaching the child deep breathing and coughing exercises

This will promote proper lung expansion.

4.) Auscultate lung fields, noting areas of decrease or absence of airflow and

To identify areas of consolidation and determine possible bronchospasm

Nursing Care plan for case presentation > increased WBC >count of 10.7 CXR= pulmonary fibrosis versus subsegmental atelectasis,left

Ineffective airway clearance

multiplication l v Irritation of the airways l V Increase goblet cells l v Increase mucus production i V Cough

adventitious breath sounds 5.) Advise to increase fluid intake

or obstruction

keeps mucus Long term: secretions moist and easier to After the entire expel hospitalization, the patient will manifest 6.) Maintain clear airway and relaxed, calm Establish effective breathing, and nonoptimal rest/ the patient will stimulating sleep pattern. maintain patent environment airway as manifested by clear breath sounds, 7.) Provided parents normal rate of and The patient and respiration, patient with parents should and effective cough. health be teachings on : taught the a. care of used basics of tissues infection control b. proper to handwashing prevent techniques transmission c. covering of of mouth microorganisms. and nose when coughing or blowing

Nursing Care plan for case presentation

Ineffective airway clearance


Dependent: 1.) Suction as order by the physician Help the body rid the lungs of mucous thus allowing easier breathing and agility

2.) Administering all prescribed medications, such as antibiotics and bronchodilators as prescribed.

It reduce bronchospasm, mobilize secretions, and Dilation of airways.

3.)Provide supplemental It helps in humidification via use of liquefying nebulizer . secretions for better and faster expectorating the secretions

Nursing Care plan for case presentation

Ineffective airway clearance

Collaborative: 1. Carbocisteine syrup 5ml P.O TID C:Mucolytic I: Acute/chronic disorders of the upper &lower respiratory tract associated with the secretion & formation of excessive and viscid mucus CI: active peptic ulcer. Hypersensitivity to carbocisteine, pregnant. AR: Nausea, headache, vomiting, anorexia, gastric discomfort, diarrhea, GI bleeding NR: 1.Assess the patient for any history of hypersensitivity or Reduces the viscosity of bronchial secretions &facilitate expectoration

Nursing Care plan for case presentation

Ineffective airway clearance

allergy to Carbocisteine. 2. Special precautions: GI bleeding, pregnancy 3. Special precaution: history of gastric or duodenal ulcer & GI bleeding. Pregnancy & lactation. 4. Use with caution in patients with a history of gastric or duodenal ulcer and gastrointestinal bleeding since mucolytics may disrupt the gastric mucosal barrier. 1. Salbutamol with ipratropium (duavent neb, 1 neb q8) C: Antiasthmatic I: Relieve or prevention of bronchospasm inpatients with reversible obstructive

Causes bronchodilation

Nursing Care plan for case presentation

Ineffective airway clearance

airway disease such as Bronchial Asthma. CI: Hypersensitivity to any component of Duavent or to atropine AR: Bronchospasm, Cough, Headache, tremors, dry mouth, palpitations, muscle cramps. NR: 1. position patient on high back rest position.. 2. do back tapping after you nebulize the patient. not give a food immediately it can cause vomiting

and inhibits secretion