Ineffective Airway Clearance - Pneumonia Nursing Care Plan

Pneumonia Nursing Care Plans ASSESSMENT

OBJECTIVES

NURSING

RATIONALE

EXPECTED OUTCOMES

INTERVENTIONS 

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With unproductive cough With wheezes and crackles auscultated on left lower lungfield. Presence of clear watery discharge from her nose Restlessness Irritability

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.

1. Establish rapport to patient and SO 2. Assess patient’s condition 3. Monitor and record V/S 4. Auscultate lung fields, noting areas of decreased/absent airflow and adventitious adventitious breath sounds 5. Assist patient to change position every 30 minutes 6. Elevate head of bed and align head in the middle 7. Provide health teachings regarding effective coughing and deep breathing exercise. 8. Encourage to increase fluid intake. 9. Encourage steam inhalation 10. Administer meds as ordered

1. To gain the trust and cooperation 2. To know and determine patient’s needs 3. To establish base line data 4. To identify areas of  consolidation and determine possible bronchospasm or obstruction. 5. To mobilize secretions 6. To facilitate breathing 7. To expel the mucous 8. To liquefy secretions 9. To moisten secretions and alleviate congestion 10. To reduce bronchospasm and mobilize secretion

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration shall have improved and difficulty of  breathing shall have been relieved.

Long Term:

After 3 – 4 days of nursing interventions, the patient will have been able to maintain a patent airway.