Ineffective Airway Clearance

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective airway Short term: Independent: After 8 hours of
 “Nahihirapan clearance related After 8 hours of  Prioritize the nursing
ako huminga to ineffective cough nursing  Assess airway maintaining of intervention, the
dahil sa plema and retained interventions, the for patency. the airway. patient was able to:
ko na hindi ko secretions. client will be able
mailabas” as to:  Assess the  RR and rhythm  Maintain the
verbalized by  Maintain airway respiratory changes are airway patency,
the patient. patency. function, such early warning her lung sounds
as breath signs of return to
Objective:  Patient’s lungs sounds, rate, impending normal and
 Difficulty of sounds will be rhythm, and respiratoy clear to
breathing, clear to depth. difficulties. auscultate, her
elevated auscultate. respiratory rate
shoulders.  Place client in  To promote decreases from
 Abnormal  Sustain RR semi-or high – lung expansion 25cpm to 18pm
breath sounds: within normal fowlers and productive which is
Wet crackles on range (12-20) position. Assist coughing . normal, she can
both lung fields. client with breathe
 Restless  Patient will be coughing and normally
free of dyspnea. deep breathing without any
Vital Signs: exercise. difficulties and
 RR: 25 cpm  Patient will be can
 PR: 110 bpm able to  Clear secretions  To prevent demonstrate
 Temp: 38*C demonstrate from mouth obstruction and correct
 BP: 130/80 correct and trachea, as aspiration. coughing and
coughing and necessary. breathing
deep breathing techniques.
techniques.
Long term:  Assess cough  Most helpful After 1 day of
After 1 day of for way to remove nursing
nursing effectiveness secretions. intervention, the
intervention, the and patient was able to:
client will be able: productivity.
 Expectorate  Expectorate the
retained  Maintain fluid  High fluid retained
secretions and intake of atleast intake helps secretions and
maintain 2500mL/day. thin secretions. maintain a
normal normal
breathing  Auscultate the  To rule out if breathing
pattern. lungs for the bronchial pattern.
presence of sounds and
normal and crackles are Goal Met
adventitious  present.
breath sounds.

Collaborative:  Prevents drying

 Humidify of mucous
inspired mem. & helps
oxygen. thin secretions.

 Administer  Reduces
medications, as thickness and
indicated, for stickiness of
Example: pulmonary
Mucolytic secretions to
Agents, such as facilitate
acetylcysteine. clearance.