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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 fowler’s 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
7. health be teachings on : taught the a. and nonoptimal rest/ the patient will stimulating sleep pattern. patient with parents should and effective cough. maintain patent environment airway as manifested by clear breath sounds. proper to handwashing prevent techniques transmission c. and nose when coughing or blowing . covering of of mouth microorganisms. calm Establish effective breathing.) Provided parents normal rate of and The patient and respiration. care of used basics of tissues infection control b.) Advise to increase fluid intake or obstruction keeps mucus Long term: secretions moist and easier to After the entire expel hospitalization.) Maintain clear airway and relaxed.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 5.7 CXR= pulmonary fibrosis versus subsegmental atelectasis. the patient will manifest 6.Nursing Care plan for case presentation > increased WBC >count of 10.
Nursing Care plan for case presentation Ineffective airway clearance nose Dependent: 1.)Provide supplemental It helps in humidification via use of liquefying nebulizer . such as antibiotics and bronchodilators as prescribed. mobilize secretions. and Dilation of airways. It reduce bronchospasm.) Administering all prescribed medications. secretions for better and faster expectorating the secretions .) Suction as order by the physician Help the body rid the lungs of mucous thus allowing easier breathing and agility 2. 3.
Nursing Care plan for case presentation Ineffective airway clearance Collaborative: 1. AR: Nausea. diarrhea.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. GI bleeding NR: 1. gastric discomfort. Hypersensitivity to carbocisteine.Assess the patient for any history of hypersensitivity or Reduces the viscosity of bronchial secretions &facilitate expectoration . pregnant. vomiting. headache. Carbocisteine syrup 5ml P. anorexia.
Salbutamol with ipratropium (duavent neb. Special precautions: GI bleeding. 2. Special precaution: history of gastric or duodenal ulcer & GI bleeding. 1 neb q8) C: Antiasthmatic I: Relieve or prevention of bronchospasm inpatients with reversible obstructive Causes bronchodilation . pregnancy 3. 1. Pregnancy & lactation. Use with caution in patients with a history of gastric or duodenal ulcer and gastrointestinal bleeding since mucolytics may disrupt the gastric mucosal barrier. 4.Nursing Care plan for case presentation Ineffective airway clearance allergy to Carbocisteine.
. Cough. NR: 1. 2. CI: Hypersensitivity to any component of Duavent or to atropine AR: Bronchospasm. tremors. muscle cramps. 3.do not give a food immediately it can cause vomiting and inhibits secretion . palpitations. Headache. dry mouth.Nursing Care plan for case presentation Ineffective airway clearance airway disease such as Bronchial Asthma. position patient on high back rest position. do back tapping after you nebulize the patient.