Medical Ward Ncp

Topics: Asthma, Respiratory system, Mucus Pages: 3 (296 words) Published: February 25, 2012
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.







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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