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    Nursing Care Plan

    Uploaded by

    Marielle Soriano
    The nursing care plan addresses ineffective airway clearance in a patient. Objectives include displaying a patent airway with clear breath sounds and absence of dyspnea and cyanosis after 8 hours of interventions. Interventions include assessing respiratory status, positioning changes, deep breathing exercises, coughing techniques, suctioning as needed, oral fluids, respiratory treatments, medications, oxygen, and monitoring. After 8 hours, the goal was partially met as the patient identified airway clearance behaviors and displayed a patent airway, but dyspnea and cyanosis were still present.

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    Nursing Care Plan

    Uploaded by

    Marielle Soriano
    496 views3 pages
    The nursing care plan addresses ineffective airway clearance in a patient. Objectives include displaying a patent airway with clear breath sounds and absence of dyspnea and cyanosis after 8 hours of interventions. Interventions include assessing respiratory status, positioning changes, deep breathing exercises, coughing techniques, suctioning as needed, oral fluids, respiratory treatments, medications, oxygen, and monitoring. After 8 hours, the goal was partially met as the patient identified airway clearance behaviors and displayed a patent airway, but dyspnea and cyanosis were still present.

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    The nursing care plan addresses ineffective airway clearance in a patient. Objectives include displaying a patent airway with clear breath sounds and absence of dyspnea and cyanosis after 8 hours of interventions. Interventions include assessing respiratory status, positioning changes, deep breathing exercises, coughing techniques, suctioning as needed, oral fluids, respiratory treatments, medications, oxygen, and monitoring. After 8 hours, the goal was partially met as the patient identified airway clearance behaviors and displayed a patent airway, but dyspnea and cyanosis were still present.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    496 views3 pages

    Nursing Care Plan

    Uploaded by

    Marielle Soriano
    The nursing care plan addresses ineffective airway clearance in a patient. Objectives include displaying a patent airway with clear breath sounds and absence of dyspnea and cyanosis after 8 hours of interventions. Interventions include assessing respiratory status, positioning changes, deep breathing exercises, coughing techniques, suctioning as needed, oral fluids, respiratory treatments, medications, oxygen, and monitoring. After 8 hours, the goal was partially met as the patient identified airway clearance behaviors and displayed a patent airway, but dyspnea and cyanosis were still present.

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    NURSING CARE PLAN

    Assessment
    S-

    Objectives :

    RR- 24
    Abnormal
    breath sounds
    use of
    accessory
    muscles
    Dyspnea
    Cyanosis
    Cough
    with sputum
    production

    Nursing Diagnosis
    Planning
    Ineffective Airway After 8 hours of Nursing
    Clearance related
    Intervention the patient
    to
    will :
    Tracheal bronchial
    inflammation,

    Identify/demonst
    decrease energy
    rate behaviors to
    and fatigue
    achieve airway
    clearance.

    Intervention
    Assess
    rate/depth
    respirations
    and
    movement.

    of
    chest

    Rationale
    Tachypnea, shallow respirations, and
    asymmetric chest movement are
    frequently present because of
    discomfort of moving chest wall
    and/or fluid in lung.

    Auscultate lung fields, noting


    areas of decreased/absent
    airflow and adventitious
    breath sounds, e.g., crackles,
    wheezes.

    Elevate head of bed, change


    position frequently

    Lowers diaphragm, promoting chest


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

    Assist patient with frequent


    deep-breathing
    exercises.
    Demonstrate/help
    patient
    learn to perform activity, e.g.,
    splinting chest and effective
    coughing while in upright
    position.

    Deep breathing facilitates maximum


    expansion of the lungs/smaller
    airways. Coughing is a natural selfcleaning mechanism, assisting the
    cilia to maintain patent airways.
    Splinting reduces chest discomfort,
    and an upright position favors deeper,
    more forceful cough effort.

    Suction as indicated (e.g.,


    frequent or sustained cough,
    adventitious breath sounds,
    desaturation related to airway
    secretions).

    Stimulates cough or mechanically


    clears airway in patient who is unable
    to do so because of ineffective cough
    or decreased level of consciousness.

    Display patent
    airway with breath
    sounds clearing;
    absence of dyspnea,
    cyanosis.

    Decreased airflow occurs in areas


    consolidated with fluid. Bronchial
    breath sounds (normal over bronchus)
    can also occur in consolidated areas.
    Crackles, rhonchi, and wheezes are
    heard on inspiration and/or expiration
    in response to fluid accumulation,
    thick
    secretions,
    and
    airway
    spasm/obstruction.

    Evaluation
    Goal partially met.
    After 8 hours of Nursing
    Intervention the patient :

    Identified/demonstrated
    behaviors to achieve
    airway clearance.

    Displayed patent airway


    with breath sounds
    clearing; absence of
    dyspnea, cyanosis.

    Force fluids to at least 3000


    mL/day
    (unless
    contraindicated, as in heart
    failure). Offer warm, rather
    than cold, fluids.

    Fluids (especially warm liquids) aid


    in mobilization and expectoration of
    secretions

    Assist with/monitor effects of


    nebulizer treatments and
    other
    respiratory
    physiotherapy, e.g., incentive
    spirometer, IPPB, percussion,
    postural drainage. Perform
    treatments between meals and
    limit fluids when appropriate.

    Facilitates liquefaction and removal


    of secretions. Postural drainage may
    not be effective in interstitial
    pneumonias or those causing alveolar
    exudate/destruction. Coordination of
    treatments/schedules and oral intake
    reduces likelihood of vomiting with
    coughing, expectorations.

    Administer medications as
    indicated:
    mucolytics,
    expectorants,
    bronchodilators, analgesics.

    Aids in reduction of bronchospasm


    and mobilization of secretions.
    Analgesics are given to improve
    cough effort by reducing discomfort,
    but should be used cautiously because
    they
    can
    decrease
    cough
    effort/depress respirations.

    Provide supplemental fluids,


    e.g., IV, humidified oxygen,
    and room humidification

    Fluids are required to replace losses


    (including insensible) and aid in
    mobilization of secretions. Note:
    Some studies indicate that room
    humidification has been found to
    provide minimal benefit and is
    thought to increase the risk of
    transmitting infection.

    Monitor serial chest x-rays,


    ABGs,
    pulse
    oximetry
    readings.

    Follows progress and effects of


    disease process/therapeutic regimen,
    and facilitates necessary alterations in
    therapy.

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