NURSING CARE PLAN

INEFFECTIVE AIRWAY CLEARANCE

CUESSUBJECTIVE OBJECTIVE

“ Oo, magtukartukar akong ubo. Usahay kay nay plema,” as verbalized by the patient.

= productive cough = fatigue = guarding over the chest during forceful coughing = slight wheezing = CXR shows positive hasty infiltrates in left upper lung field = yellowish colored mucus secretions was noted in minimum amount = VS of: T= 37.3 BP= 110/70 CR= 79 PR= 77 RR= 22 = grimace face was noted while patient is coughing

NEEDACTIVITY

TOLERANCE

NURSING DIAGNOSISIneffective airway clearance related to presence of

tracheobronchial secretions as evidenced by presence of infiltrates in lungs.

RATIONALE:Pneumonia is an acute bacterial or viral infection that causes

inflammation of the lung parenchyma (alveolar spaces & interstitial tissue). As a result of the inflammation, the involved lung tissue becomes edematous & the air spaces filled with exudates (consolidation in affected lung fields as shown on XRAY), gas exchange cannot occur, & non oxygenated blood is shunted into the vascular system, causing hypoxemia.

Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain airway patency. Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway.

OBJECTIVE OF CAREAfter 8 hours of nursing interventions, the patient is

expected to show negative signs of any airway obstruction as evidenced by:

A. Cough out secretions without difficulty as evidence by absence of guarding activity over the chest while coughing;

B. Show feeling of comfort through facial expression;

C. Verbalize relief from difficulty in breathing and;

D. Maintain VS within the normal prescribed range with T=36.5-37.5BP= 90/60

NURSING INTERVENTIONS1. Position pt. on a high back rest position with head elevated.

2. Encourage deep breathing & coughing exercise.

3. Encourage splinting o the chest & effective coughing while in upright position.

4. Instruct to increase oral fluid intake. Encourage intake of lukewarm water rather than cold water.

5. Monitor VS regularly.

6. Auscultate regularly the pt’s lung fields for presence of adventitious breath sounds. 7. Encourage to comply to medications.

8. Instruct to have adequate daily nutritional intake of foods such as fresh fruits rich in fiber and vegetables.

9. Provide pt the opportunity to rest.

10. Discourage smoking.

EVALUATION……..

After 8 hours of nursing interventions the patient was able

to show negative signs of airway obstruction as evidenced

by:a. coughing out of yellowish colored secretions in minimum

amount without difficulty as evidenced by diminished

guarding/splinting activity over the chest during coughing;

b. able to smile and laugh spontaneously and;

c. the patient also verbalizes “Oo, makaginhawa ko og

tarong,” and;

d. VS at: T= 36.5

CR= 86

BP= 110/70PR= 85

RR= 22