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    XI. Nursing Care Plan: Nursing Diagnosis Planning Intervention Rationale Evaluation

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    bevslorenz
    - The patient was experiencing ineffective airway clearance due to an accumulation of excessive mucus secretions in the tracheobronchial area, as evidenced by difficulty breathing. - The nurse assessed the patient's knowledge of their condition, monitored vital signs, elevated the head of the bed and changed positions every 2 hours to promote secretion clearance. Deep breathing and coughing exercises were also encouraged. - After 30 minutes to 1 hour of nursing intervention, the patient was able to expel secretions easily, indicating improved airway clearance.

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    XI. Nursing Care Plan: Nursing Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    bevslorenz
    14 views2 pages
    - The patient was experiencing ineffective airway clearance due to an accumulation of excessive mucus secretions in the tracheobronchial area, as evidenced by difficulty breathing. - The nurse assessed the patient's knowledge of their condition, monitored vital signs, elevated the head of the bed and changed positions every 2 hours to promote secretion clearance. Deep breathing and coughing exercises were also encouraged. - After 30 minutes to 1 hour of nursing intervention, the patient was able to expel secretions easily, indicating improved airway clearance.

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    NCP

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    - The patient was experiencing ineffective airway clearance due to an accumulation of excessive mucus secretions in the tracheobronchial area, as evidenced by difficulty breathing. - The nurse assessed the patient's knowledge of their condition, monitored vital signs, elevated the head of the bed and changed positions every 2 hours to promote secretion clearance. Deep breathing and coughing exercises were also encouraged. - After 30 minutes to 1 hour of nursing intervention, the patient was able to expel secretions easily, indicating improved airway clearance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    14 views2 pages

    XI. Nursing Care Plan: Nursing Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    bevslorenz
    - The patient was experiencing ineffective airway clearance due to an accumulation of excessive mucus secretions in the tracheobronchial area, as evidenced by difficulty breathing. - The nurse assessed the patient's knowledge of their condition, monitored vital signs, elevated the head of the bed and changed positions every 2 hours to promote secretion clearance. Deep breathing and coughing exercises were also encouraged. - After 30 minutes to 1 hour of nursing intervention, the patient was able to expel secretions easily, indicating improved airway clearance.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    XI.

    Nursing Care Plan

    Nursing Planning Intervention Rationale Evaluation


    Diagnosis
    Ineffective After -Assessed patient’s knowledge -Patient education will vary on disease as well as After
    airway 30minutes to about his condition. the patient’s cognitive level. 30minutes to
    clearance 1 hour of 1 hour of
    related to nursing -Monitored vital signs -To gather baseline data and noted changes. nursing
    accumulation intervention, intervention,
    of excessive the patient -To take advantage of gravity decreasing pressure the patient
    mucus will expel -Elevated head of bed/ change on diaphragm. was able to
    secretions on secretions position every 2 hours. expelled
    tracheobronch easily to -To maximize effort in mobilizationof secretions. secretion
    ial as promote -Encouraged deep breathing and easily.
    evidenced by airway coughing exercises.
    difficulty of clearance. -To promote systematic hydration and to help
    breathing. -Increase oral fluid intake to liquefy secretions.
    atleast 2000 ml/day.

    -Discourage use of oil based


    products around nose. -To prevent aspiration into lungs.

    -Monitored vital signs and


    observed for signs of respiratory
    distress. -To assess changes and noting complication.

    -Provided with information about


    the necessity of expectorating
    secretions.
    -For the patient to be aware of the importance of
    -Given bronchodilators expectorating secretions.
    (Salbutamol nebulizer) as ordered
    by doctor.
    -For mobilization of secretions.

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