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Ineffective airway clearance related to excessive mucus secretions as evidence by abnormal breathing sounds.
Nursing
Assessment
Nursing
Diagnosis
Expected out
come
Planning Rational Implementation Evaluation
Subjective data:
My pt says, ”I can’t
breaths properly”
Objective data:
dyspnea
difficulty in
vocalizing
abnormal breath
sound
cyanosis
increased
respiratory rate
Ineffective airway
clearance related
to excessive mucus
secretions as
evidence by
abnormal
breathing sounds.
Clear the airway as
evidence by
normal breathing
sounds.
Check vital signs
Provide
comfortable
position.
perform
Chest
physiotherapy.
Perform deep
breathing and
coughing
exercise.
Provide
bronchodilator.
To check current
health status.
For comfort and
normal breathing
To expel cough
To expel cough
To prevent
dyspnea
Checked vital
signs
T: 98.8°F
P: 76 Beat/min
R: 16
Breaths/min
BP: 124/76
mmHg
Provided
comfortable
position.(
Fowler’s
position)
performed
Chest
physiotherapy.
Performed deep
breathing and
coughing
exercise.
Provided
bronchodilator.
Airway is cleared
as evidence by
normal breathing
sounds.