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Nursing Care Plan Ineffective Airway Clearance: Assessment Diagnosis Outcome Identification

The nursing care plan addresses ineffective airway clearance in a client experiencing continuous dry coughing. The plan involves assessing the client's respiratory status, diagnosing ineffective airway clearance due to retained secretions, and setting short-term and long-term outcomes to maintain a clear airway and improve breathing. Interventions include monitoring breathing, suctioning the airway, encouraging coughing exercises, limiting activity, and giving medications to clear secretions. Evaluation found the short-term goal of maintaining a clear airway was met, as was the long-term goal of reduced congestion and improved breathing.

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704 views9 pages

Nursing Care Plan Ineffective Airway Clearance: Assessment Diagnosis Outcome Identification

The nursing care plan addresses ineffective airway clearance in a client experiencing continuous dry coughing. The plan involves assessing the client's respiratory status, diagnosing ineffective airway clearance due to retained secretions, and setting short-term and long-term outcomes to maintain a clear airway and improve breathing. Interventions include monitoring breathing, suctioning the airway, encouraging coughing exercises, limiting activity, and giving medications to clear secretions. Evaluation found the short-term goal of maintaining a clear airway was met, as was the long-term goal of reduced congestion and improved breathing.

Uploaded by

Angelokeizer Gavino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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NURSING CARE PLAN

INEFFECTIVE AIRWAY
CLEARANCE
Assessment Diagnosis Outcome Identification

Planning Intervention
Evaluation
Assesment
Subjective:
“nahihirapan ako huminga dahil sa
tuloy-tuloy na pag ubo ko” as
verbalized by the client
 
Objective:
 Difficulty of breathing
 Difficulty verbalizing
 Alteration in respiratory rate or
pattern
 Wide-eyed look; restlessness
Diagnosis
Ineffective airway
clearance related to
retained secretions as
evidenced by continuous
Dry coughing.
Outcome Identification
After 8 hours, the client
will be able to maintain
airway
patency. Expectorate/clear
secretions readily and
demonstrate behaviors to
improve or maintain clear
airway.
Planning
Short Term:
After 8 hours of nursing intervention, the
client will be able to maintain airway
patency. Expectorate/clear secretions
readily and demonstrate behaviors to
improve or maintain clear airway.
 
Long Term:
After One Week of nursing intervention, The
client will be able to demonstrate absence
or reduction of congestion with breath
sounding clear, noiseless respirations, and
improve oxygen exchange.
Intervention
Independent Nursing Interventions:

 Assess level of consciousness/cognition and ability to


protect own airway.

Rationale: This information is essential for identifying


potential for airway problems, providing baseline level of
care needed, and influencing choice of interventions.

 Monitor respirations and breath sounds, noting rate and


sounds.

Rationale: Indicative of respiratory distress and/or


accumulation of secretions.

 Evaluate client’s cough/gag reflex, amount and type of


secretions, and swallowing ability.

Rationale: to determine ability to protect own airway.


Intervention
Independent Nursing Interventions:

 Suction nose, mouth, and trachea prn using correct-size


catheter and suction timing for child or adult.

Rationale: to ;clear airway when excessive or viscous


secretions are blocking airway or client is unable to
swallow or cough effectively.

 Encourage deep-breathing and coughing exercises or


splint chest/incision to maximize effort.

Rationale: To observe for signs of respiratory distress.

 Provide information about the necessity of raising and


expectorating secretions versus swallowing them.

Rationale: To report changes in color and amount in the


event that medical intervention may be needed to prevent
or treat infection.
Intervention
Independent Nursing Interventions:

 Encourage/provide opportunities for rest; limit


activities to level of respiratory tolerance.

Rationale: This is to prevent/reduce fatigue.

Dependent Nursing Interventions:

 Administer medications as indicated.

Rationale: To relax smooth respiratory musculature, reduce


airway edema, and mobilize secretions.
Evaluation
Short Term:
After 8 hours of nursing intervention, the
client-maintained airway patency. Expectorated
and cleared secretions readily and demonstrated
behaviors that improved or maintained clear
airway.
 
Long Term:
After one week of nursing intervention, the
client demonstrated absence or reduction of
congestion with breath sounding clear, noiseless
respirations, and improved oxygen exchange.
 
Goal was met.

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