Nsg Process Ineffective airway.pptx

Sample Nursing Care Plan for ineffective airway clearance

1. Sample Nursing Care Plan Ineffective airway clearance Prof Nagamani.T

2. Nursing Care Plan must consist of the following steps Assessment Nursing Diagnosis Expected Outcome/Goal Nursing Intervention Rationale Implementation Evaluation

3. Assessment Nursing Diagnosis Goal Intervention/ Implementation Rationale Evaluation Subjective data Patient complains of severe cough during nights, unable to remove secretions, fatigue, lack of sleep Objective Data Presence of cough, Secretions, 26 breaths/ mt , dyspnoea In effective airway clearance related to cough and i nability to remove airway secretions Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths. Assess airway for patency. Auscultate lungs for presence of normal or adventitious breath sounds Maintaining patent airway is always the first priority to understand patient condition Abnormal breath sounds can be heard as fluid and mucus accumulate. This may indicate ineffective airway clearance.

4. Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. Position the patient upright if tolerated. Regularly check the patient’s position to prevent sliding down in bed. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. Upright position limits abdominal contents from pushing upward and inhibiting lung expansion. This position promotes better lung expansion and improved air exchange.

5. Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation Encourage patient to increase fluid intake to 3 liters per day if not contra indicated. Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). Fluids help minimize mucosal drying and maximize ciliary action to move secretions. The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing.

6. Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation Use universal precautions: gloves, goggles, and mask, as appropriate.  Provide Chest physiotherapy and nebulizer management as indicated. As protection health care workers should use universal precautions while caring the patient. Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning.

7. Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation Provide postural drainage, percussion, and vibration as ordered. Provide oral care every 4 hours. it should be used only when prescribed because it can cause harm if patient has underlying conditions such as cardiac disease or increased intracranial pressure. Oral care freshens the mouth after respiratory secretions have been expectorated.

8. Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants noting effectiveness and side effects. A variety of medications are prepared to manage specific problems. Most promote clearance of airway secretions and may reduce airway resistance. Patient has demonstrated increased air exchange. 20 breaths/minute. Patient coughed out the sputum and felt relaxed.

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