Medical Ward Ncp

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Ineffective Airway Clearance

The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

ASSESSMENT

NURSING DIAGNOSIS

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

S> Ø

O> Patient manifested the ff:

- with unproductive cough

-with wheezes and crackles auscultated on left lower lungfield.
- presence of clear watery discharge from her nose

> Patient may manifest the ff:

- restlessness

- irritability

Ineffective airway clearance related to presence of secretions secondary to pneumonia.

Short Term:

After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved.

Long Term:

After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.

>Establish rapport to patient and SO

>Assess patient’s condition

>Monitor and record V/S

>Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds

>Assist patient to change position every 30 minutes

>Elevate head of bed and align head in the middle

>Provide health teachings regarding effective coughing and deep breathing exercise.

>Encourage to increase fluid intake.

>Encourage steam inhalation

>Administer meds as ordered

>To gain the trust and cooperation

>To know and determine patient’s needs

>To establish base line data

>To identify areas of consolidation and determine possible bronchospasm or obstruction.

>To mobilize secretions

>To facilitate breathing

>To expel the mucous...
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