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Ineffective airway clearance

Nr. Nursing Diagnosis Date Nursing Intervention/s and tasks Sign.

Ineffective airway clearance Airway Management

Related factors: Monitor respiratory rate and depth;
Chronic obstructive pulmonary disease Administer O2 if indicated
Symptoms / Risk factors: Position the client to optimize respiration (head of bed elevated 45 degrees)
Adventitious breath sounds (rales, crackles, rhonchi, wheeze Encourage effective coughing and deep breathing
Cough, ineffective or absent Limit exerciss as appropiate
Dyspnea and difficulty breathing Note amount, color, and consistency of secretions
Excessive mucus Perform chest physical therapy, as appropriate
Temp > 37.5 Teach and demostrate use of O2(saturation) monitor and how to administer O2
Outcome / Goal: Teach patient how to use prescribed inhalers, as appropriate
Maintain patent airway with breath sounds clear or clearing
Cough Enhancement
Decreased mucus production Instruct how to cough effectively
Improved breathsounds
Medication Administration
O2 sat. > 90% Medication: Epinephrine, Antihistamin and Steroids (if not already done)
Temp < 37.5 Administer medication as prescribed
Assist patient in taking medication
Monitor patient for the therapeutic effect of the medication
Teach patient how to use prescribed inhalers, as appropriate
Vital Signs Monitoring
Monitor blood pressure, pulse, temperature, and respiratory status, as appropria

Plan created:18-05-2020 by:_________________________________________

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