BUKIDNON STATE UNIVERSITY
FORTICH ST. SAYRE HIGHWAY,
Date Formulated: January 14, 2022
Problem 1 (PE Format): ineffective airway clearance related to hyperplasia of the bronchial walls
Level of Prioritization: high priority
Cause Analysis: hyperplasia of the bronchial walls is common in smokers and usually reflects the chronic bronchitis form of chronic obstructive pulmonary
disease (COPD). In never smokers or in younger patients, consider other causes of bron- chial inflammation, including asthma.
Goals: the patient will maintain clear, open airways, normal breath sounds , normal respiratory rate and ability to effectively cough up secretion after treatment
CUES
Subjective:
 The patient verbalized that
she has a shortness of
breath, and can’t breath
lying down, she is also
experiencing “pain” in her
“chest”.
Objective:
 Shallow respiration
 chest expansion of <3cm.
 inspiratory crackles
 diminished breath sounds
 Respirations, 28
 Excessive use of
accessory muscle
 Shortness of breath
 Tachycardia
 Cough
 Fever
 Cyanosis
 Nasal flarring
MALAYBALAY CITY, BUKIDNON
DESIRED OUTCOMES
Short term:
• Client will Maintain
airway patency,
Expectorate/clear
secretions readily.
• Demonstrate
absence/reduction of
congestion with breath
sounding clear,
noiseless respiration,
and improved oxygen
exchange
Long term:
• Client will Verbalize
understanding of cause
and therapeutic
management regimen.
• Demonstrate behaviors
to improve or maintain
clear airway, Identify
potential complications
and how to initiate
appropriate preventive
or corrective actions.
 Patient will
display/maintain patent
airway with breath sounds
clearing; absence of
dyspnea, cyanosis.
NURSING CARE PLAN
INTERVENTIONS
Independent:
 Evaluate client’s
cough/gag reflex, amount
and type of secretions, and
swallowing ability to
determine ability to
protect own airway.
 Perform/assist the client in
learning airway clearance
techniques
 Administer medication as
indicated
 Increase fluid intake to at
least 2000 ML/day within
cardiac tolerance
 Suction nose, mouth, and
trachea prn to clear airway
when excessive or viscous
secretions are blocking
airway or cli ent is unable
to swallow or cough
effectively.
 Encourage deep-breathing
and coughing exercises or
splint chest/incision to
maximize effort.
 Instruct in/review
postoperative breathing
exercises, effective
coughing, and use of
adjunct devices (e.g.,
intermittent positive
pressure breathing or
incentive spirometer) in
preoperative teaching.
 Assist with procedures
(e.g., bronchoscopy or
tracheostomy
 Administer analgesics
 Perform or assist the client
in learning airway
clearance techniques such
as postural drainage and
percussion (chest physical
therapy [CPT]), flutter
devices, high-frequency
chest compression with an
inflatable vest,
intrapulmonary percussive
ventilation administered
by a percussinator, and
active cycle breathing
(ACB).
Collaborative:
• Coordinate with a
respiratory therapist for
chest physiotherapy
and nebulizer
management as
indicated.
RATIONALE EVALUATION
● To determine ability to Short term
protect own airways Goal met. Patient was able to
recover and maintain airway
patency with clear breath
sounds
● Various
therapies/modalities
may be required to
acquire and maintain
edequate airways and
improve respiratory
function
● To reduce airways
edema and mobilize
secretion Long term:
Goal met. Patient was able to
● To help prevent the expectorate remaining
accumulation of secretions and maintained
viscous secretion normal breathing pattern.
● To clear airways when
excessive viscous
secretion that are
blocking it
● To help expectorate
remaining secretion by
deep breathing and
coughing exercise
● To help provide
techniques of postural
drainage and chest
percussion to mobilize
secretion from smaller
airways that cannot be
eliminated by coughing
 To clear/maintain open
airway
 To improve cough when
pain is inhibiting effort.
(Caution: Overmedication
can depress respirations
and cough effort.)
 Various
therapies/modalities may
be required to acquire and
maintain adequate airways
and improve respiratory
function and gas exchange