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    Ineffective Airway Clearance

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    DarkCeades
    1. The client was experiencing difficulty breathing and coughing up thick mucus. 2. The nursing diagnosis was ineffective airway clearance related to excess secretions in the bronchi. 3. The goal was to lessen the client's secretions after an 8-hour shift through teaching proper coughing techniques, chest percussion, positioning for drainage, and administering antibiotics or intravenous fluids as needed.

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    Ineffective Airway Clearance

    Uploaded by

    DarkCeades
    8K views3 pages
    1. The client was experiencing difficulty breathing and coughing up thick mucus. 2. The nursing diagnosis was ineffective airway clearance related to excess secretions in the bronchi. 3. The goal was to lessen the client's secretions after an 8-hour shift through teaching proper coughing techniques, chest percussion, positioning for drainage, and administering antibiotics or intravenous fluids as needed.

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    Nursing care plan

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    1. The client was experiencing difficulty breathing and coughing up thick mucus. 2. The nursing diagnosis was ineffective airway clearance related to excess secretions in the bronchi. 3. The goal was to lessen the client's secretions after an 8-hour shift through teaching proper coughing techniques, chest percussion, positioning for drainage, and administering antibiotics or intravenous fluids as needed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC or read online from Scribd
    Download as doc
    8K views3 pages

    Ineffective Airway Clearance

    Uploaded by

    DarkCeades
    1. The client was experiencing difficulty breathing and coughing up thick mucus. 2. The nursing diagnosis was ineffective airway clearance related to excess secretions in the bronchi. 3. The goal was to lessen the client's secretions after an 8-hour shift through teaching proper coughing techniques, chest percussion, positioning for drainage, and administering antibiotics or intravenous fluids as needed.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC or read online from Scribd
    Download as doc
    of 3

    Cues Nursing Analysis Goal and Interventions Rationale Evaluation

    Diagnosis Objectives

    Subjective: Ineffective Increased Goal: After an Goal met.


    - The client Airway amount and 8-hour shift,
    verbalized, Clearance viscosity of the client’s
    “Nahihiripan related to secretions secretions
    talaga ako Secretions in and/or inability would be
    huminga lalo na the bronchi to clear lessened.
    nung una kong secretions
    punta dito sa through the Objectives: 1. The client
    hospital” normal cough 1. After 30 was able to
    -“1 bottle lang mechanism minutes, the expel mucous.
    nauubas kong may lead to client will be
    tubig sa isang pooling of able to expel DEVELOPMENT
    araw” secretions in mucous by: AL The patient needs to
    lower airways. a. Doing a. Teach the cough to be able to
    Pooling of proper client proper remove the mucus
    Objective: secretions leads coughing coughing (p530,
    - Adventitious to infection and technique technique. Smeltzer,Medical-
    Breath Sounds inadequate gas surgical Nursing vol.
    (Rales) exchange. 1)
    -Cough with
    phlegm (p229, SUPPLEMENTAL
    -Pale Nettina,Manual b.Apply Chest Chest physiotherapy
    of nursing b. Applying Percussion to is important in
    practice) Chest the Client. loosening and
    percussion mobilizing
    secretions.
    Indications for chest
    physiotherapy
    include sputum
    retention not
    responsive to
    spontaneous or
    directed cough,
    abnormal chest x-ray
    findings consistent
    with infiltrates or
    deterioration in
    oxygentaion. (p530,
    SUPPLEMENTAL Smeltzer,Medical-
    c. Position the surgical Nursing vol.
    c. Chest client for 1)
    Drainage Postural
    Drainage.
    The patient is placed
    in the proper
    position to drain the
    involved lung
    FACILITATIVE segments. (p530,
    d. Administrat d. Administer Smeltzer,Medical-
    ion of Antibiotics as surgical Nursing vol.
    drugs ordered 1) 2. The client
    was able to
    maintain
    2. The client For infections. adequate
    will be able to (NANDA) hydration.
    maintain
    adequate SUPPLEMENTAL
    hydration by: a. Increase the
    a. Increasing number of fluid
    oral fluid being drunk by
    intake the patient. Efficiency
    The time,
    An increased materials, and
    respiratory rate human
    leads to an increase resources were
    in insensible fluid used
    loss during economically
    exhalation and can
    lead to dehydration.
    (p530, Adequacy
    SUPPLEMENTAL Smeltzer,Medical- The numbers of
    b. Regulate the surgical Nursing vol. interventions
    b. Regulating IV fluid as 1) were sufficient.
    intravenou ordered.
    s Fluid. Appropriateness
    The
    interventions
    were suitable to
    the client’s
    Administration of this situation.
    fluid generally
    causes dilution of Acceptability
    plasma solute The
    concentration and interventions,
    forces water setting, and
    movement into cells timetable were
    to reestablish realistic to the
    intracellular and client’s
    extra cellular situation.
    equilibrium; cells
    then expand or
    swell.
    (p84,Nettina,Manual
    of nursing practice)

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