MSU-Iligan Institute of Technology

COLLEGE OF NURSING
Level II AACUP Accredited

Student Name: Level:

Group:

PNEUMONITIS
NURSING CARE PLAN

Nursing Diagnosis: Ineffective Airway Clearance

Expected Outcomes:

Short Term Objective:

Within 8 hours of comprehensive nursing interventions, the patient will be able to

identify/demonstrate behaviors to achieve airway clearance.

Long Term Objective:

Within 3 days of comprehensive nursing interventions, the patient will be able to

display/maintain a clear airway with breath sounds clearing; absence of dyspnea, cyanosis,
as evidenced by keeping a patent airway and effectively clearing secretions.

Signs and Symptoms:

● Changes in rate, depth of respirations

● Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
● Use of accessory muscles
● Dyspnea, tachypnea
● Cough, effective or ineffective; with/without sputum production
● Cyanosis
● Decreased breath sounds over affected lung areas
● Ineffective cough
● Purulent sputum
● Hypoxemia
● Infiltrates seen on chest x-ray film

Interventions Rationale Evaluation

1. Assess the rate, Altered breathing Short Term:

rhythm, and depth of patterns may occur
 MSU-Iligan Institute of Technology
COLLEGE OF NURSING
Level II AACUP Accredited

respiration, chest together with accessory Goal met. Within 8 hours of

movement, and use of muscles to increase comprehensive nursing
accessory muscles. chest excursion to interventions, the patient was able
facilitate effective to identify/demonstrate behaviors to
breathing. achieve airway clearance.

2. Assess cough
effectiveness and
productivity
3. Auscultate lung fields,
noting areas of
decreased or absent
airflow and adventitious
breath sounds: crackles,
wheezes.
Long Term:
Coughing is the most
effective way to remove Goal met. Within 3 days of
secretions. comprehensive nursing
interventions, the patient was able
Decreased airflow occurs to display/maintain a clear airway
in areas with with breath sounds clearing;
consolidated fluid. absence of dyspnea, cyanosis, as
Bronchial breath sounds evidenced by keeping a patent
can also occur in these airway and effectively clearing
consolidated areas. secretions.
Crackles, rhonchi, and
wheezes are heard on
inspiration and/or
expiration due to fluid
accumulation, thick
secretions, and airway
spasms and obstruction.

4. Observe the sputum Changes in sputum

color, viscosity, and odor. characteristics may
Report changes. indicate infection.

5. Assess the patient’s Airway clearance is

hydration status. hindered with inadequate
hydration and thickening
of secretions.

6. Elevate the head of the Doing so would lower

bed, change position the diaphragm and
frequently. promote chest
 MSU-Iligan Institute of Technology
COLLEGE OF NURSING
Level II AACUP Accredited

expansion, aeration of
lung segments,
mobilization, and
expectoration of
secretions.

7. Teach and assist the Deep breathing

patient with proper deep- exercises facilitates
breathing exercises. maximum expansion of
the lungs and smaller
airways, and improves
the productivity of
cough.

8. Suction as indicated: Stimulates cough or

frequent coughing, mechanically clears
adventitious breath airway in a patient who
sounds, desaturation cannot do so because of
related to airway ineffective cough or
secretions. decreased level of
consciousness.

9. Maintain adequate Fluids, especially warm

hydration by forcing liquids, aid in the
fluids to at least 3000 mobilization and
mL/day unless expectoration of
contraindicated. secretions. It helps
maintain hydration and
increases ciliary action to
remove secretions, and
reduces the viscosity of
secretions.

10. Monitor serial chest Follows progress and

x-rays, ABGs, pulse effects and extent of
oximetry readings. pneumonia.