NCP Ineffective Airway Clearance

CUES

NURSING DIAGNOSIS

RATI RATIO ONALE NALE

SUBJECTIVE:

Ineffective Airway Clearance related to retained secretions in the bronchi secondary to pneumonia

Normally the lungs are free from secretions. Pneumonia bacteria are invading the lung parenchyma thus, producing inflammatory process. And these responses leading to filling of the alveolar sacs with exudates leading to consolidation. The airway is narrowed thus wheezes is being heard. DOB in some cases

“Nahihirapan na siya huminga dahil sa plema hindi niya mailabas, grabe na kasi ang ubo niyan eh”

OBJECTIVES: • •

•

DOB Wheezes on both lung fields Productive Cough

PLA PLANNING NING

Short term: After 1 hour  of nursing intervention, the client will be able to maintain airway patency, clear  breath sounds.

Long Term: After 1 day of  nursing intervention, the client will be able to expectorate retained secretions and maintain normal breathing

NURSI URSIN NG INTERVETION Establis h rapport •

•

Monitor 

VS

Suction secretions PRN •

Place on orthopneic position

RATION RATIONALE ALE

to gain client’s and relatives trust to obtain baseline data to decrease secretion retained in the bronchi •

•

•

•

Elevate HOB

EVALUA EVALUATIO TION N

to maintain patent airway •

•

to take advantage of the gravity decrease pressure on the •

The client shall have maintained airway patency, clear  breath sounds (goal partially met)

The client shall have expectorated retained secretions and maintained normal breathing pattern (goal met)

orthopnea is observed.

pattern.

diaphragm.

Encoura ge deep breathing •

Give bronchodila tor as ordered

to mobilize secretion •

•

Refer  for any abnormal changes in the body •

to moisten secretions for easy expectorati on •

to medically manage any complicatio ns. •