Sample Nursing Care Plan for ineffective airway clearance

1. Sample Nursing Care Plan
Ineffective airway clearance
Prof Nagamani.T

2. Nursing Care Plan must consist
of the following steps
 Assessment
 Nursing Diagnosis
 Expected Outcome/Goal
 Nursing Intervention
 Rationale
 Implementation
 Evaluation

3. Assessme
nt
Nursing
Diagnosis
Goal Interventio
n/
Implement
ation
Rationale Evaluatio
n
Subjective
data
Patient
complains
of severe
cough
during
nights,
unable to
remove
secretions,
fatigue, lack
of sleep
Objective
Data
Presence of
cough,
Secretions,
26
breaths/mt,
In effective
airway
clearance
related to
cough and
inability to
remove
airway
secretions
Patient will
maintain
clear, open
airways as
evidence by
normal
breath
sounds,
normal rate
and depth
of
respirations,
and ability
to
effectively
cough up
secretions
after
treatments
and deep
•Assess
airway for
patency.
•Auscultate
lungs for
presence of
normal or
adventitious
breath
sounds
•Maintaining
patent airway
is always the
first priority to
understand
patient
condition
•Abnormal
breath sounds
can be heard
as fluid and
mucus
accumulate.
This may
indicate
ineffective
airway
clearance.

4. Assessme
nt
Nursing
Diagnos
is
Goal Intervention Rationale Evaluati
on
•Assess respirations.
Note quality, rate,
pattern, depth, flaring
of nostrils, dyspnea
on exertion, evidence
of splinting, use of
accessory muscles,
and position for
breathing.
•Position the patient
upright if tolerated.
Regularly check the
patient’s position to
prevent sliding down
in bed.
•An increase in
respiratory rate
and rhythm
may be a
compensatory
response to
airway
obstruction.
•Upright
position limits
abdominal
contents from
pushing
upward and
inhibiting lung
expansion.
This position
promotes
better lung
expansion and
improved air

5. Assessme
nt
Nursing
Diagnos
is
Goal Intervention Rationale Evaluati
on
•Encourage patient to
increase fluid intake
to 3 liters per day if
not contra indicated.
•Teach the patient the
proper ways of
coughing and
breathing. (e.g., take
a deep breath, hold
for 2 seconds, and
cough two or three
times in succession).
•Fluids help
minimize
mucosal drying
and maximize
ciliary action to
move
secretions.
•The most
convenient
way to remove
most
secretions is
coughing. So it
is necessary to
assist the
patient during
this activity.
Deep
breathing, on
the other hand,
promotes

6. Assessme
nt
Nursing
Diagnos
is
Goal Intervention Rationale Evaluati
on
•Use universal
precautions: gloves,
goggles, and mask,
as appropriate.
• Provide Chest
physiotherapy and
nebulizer
management as
indicated.
•As protection
health care
workers should
use universal
precautions
while caring
the patient.
•Chest
physiotherapy
includes the
techniques of
postural
drainage and
chest
percussion to
mobilize
secretions from
smaller
airways that
cannot be
eliminated by

7. Assessme
nt
Nursing
Diagnos
is
Goal Intervention Rationale Evaluati
on
•Provide postural
drainage, percussion,
and vibration as
ordered.
•Provide oral care
every 4 hours.
•it should be
used only
when
prescribed
because it can
cause harm if
patient has
underlying
conditions
such as
cardiac
disease or
increased
intracranial
pressure.
•Oral care
freshens
the mouth after
respiratory
secretions
have been

8. Assessme
nt
Nursing
Diagnos
is
Goal Intervention Rationale Evaluati
on
•Give medications as
prescribed, such as
antibiotics, mucolytic
agents,
bronchodilators, expe
ctorants noting
effectiveness and
side effects.
•A variety of
medications
are prepared to
manage
specific
problems. Most
promote
clearance of
airway
secretions and
may reduce
airway
resistance.
Patient
has
demonstr
ated
increase
d air
exchang
e.
20
breaths/
minute.
Patient
coughed
out the
sputum
and felt
relaxed.

9. Keep Watching………..