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    Ineffective Airway Clearance

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    michelle_010379
    The client was having difficulty breathing due to an inability to expel phlegm from pneumonia. The nurse's diagnosis was ineffective airway clearance related to retained secretions in the bronchi. Short term goals included establishing rapport, monitoring vital signs, suctioning secretions, and positioning the client. Long term goals were expectorating secretions and maintaining normal breathing within a day. The intervention plan included monitoring, suctioning, positioning, medications, and referrals if needed. The client partially met the short term goal of maintaining airway patency and fully met the long term goals.

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    Ineffective Airway Clearance

    Uploaded by

    michelle_010379
    1K views2 pages
    The client was having difficulty breathing due to an inability to expel phlegm from pneumonia. The nurse's diagnosis was ineffective airway clearance related to retained secretions in the bronchi. Short term goals included establishing rapport, monitoring vital signs, suctioning secretions, and positioning the client. Long term goals were expectorating secretions and maintaining normal breathing within a day. The intervention plan included monitoring, suctioning, positioning, medications, and referrals if needed. The client partially met the short term goal of maintaining airway patency and fully met the long term goals.

    Original Title

    26492499 Ineffective Airway Clearance

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    © Attribution Non-Commercial (BY-NC)

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    The client was having difficulty breathing due to an inability to expel phlegm from pneumonia. The nurse's diagnosis was ineffective airway clearance related to retained secretions in the bronchi. Short term goals included establishing rapport, monitoring vital signs, suctioning secretions, and positioning the client. Long term goals were expectorating secretions and maintaining normal breathing within a day. The intervention plan included monitoring, suctioning, positioning, medications, and referrals if needed. The client partially met the short term goal of maintaining airway patency and fully met the long term goals.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    1K views2 pages

    Ineffective Airway Clearance

    Uploaded by

    michelle_010379
    The client was having difficulty breathing due to an inability to expel phlegm from pneumonia. The nurse's diagnosis was ineffective airway clearance related to retained secretions in the bronchi. Short term goals included establishing rapport, monitoring vital signs, suctioning secretions, and positioning the client. Long term goals were expectorating secretions and maintaining normal breathing within a day. The intervention plan included monitoring, suctioning, positioning, medications, and referrals if needed. The client partially met the short term goal of maintaining airway patency and fully met the long term goals.

    Copyright:

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    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Objective

    CUES NURSING Inference NURSING RATIONALE EVALUATION


    DIAGNOSIS PLANNING INTERVETION

    SUBJECTIVE: Ineffective Normally the Short term: > establish .> to gain
    lungs are free rapport client’s and The client shall
    “Nahihirapan na Airway from secretions. After 1 hour of relatives trust have maintained
    siya huminga Pneumonia nursing > monitor VS > to obtain airway patency,
    dahil sa plema Clearance bacteria are intervention, the baseline data clear breath
    hindi niya
    invading the client will be > suction > to decrease sounds
    mailabas, grabe na
    kasi ang ubo niyan related to lung able to maintain secretions PRN secretion (goal partially
    eh” parenchyma airway patency, retained in the met)
    retained thus, producing clear breath bronchi
    secretions in the inflammatory sounds. > place on >to maintain
    OBJECTIVES: bronchi process. And orthopneic patent airway The client shall
    these responses position have
    >DOB secondary to leading to filling Long Term: > Elevate HOB >to take expectorated
    >Orthopnea pneumonia of the alveolar advantage of the retained
    >Wheezes on sacs with After 1 day of > Encourage gravity decrease secretions and
    both lung fields exudates leading nursing deep breathing pressure on the maintained
    >uses intercostal to consolidation. intervention, the diaphragm. normal breathing
    muscles upon The airway is client will be > give > to mobilize pattern
    respiration narrowed thus able to bronchodilator as secretion (goal met)
    >Productive wheezes is being expectorate ordered
    Cough heard. DOB in retained > refer for any > to moisten
    some cases secretions and abnormal secretions for
    orthopnea is maintain normal changes in the easy
    observed. breathing body expectoration
    pattern. > to medically
    manage any
    complications.
    3 PRIORITIZED PROBLEMS

    1. Ineffective airway clearance related to retained secretions in the bronchi secondary to Pneumonia

    2. Impaired physical mobility related to body weakness

    3. Ineffective cerebral tissue perfusion related to interruption in blood flow on brain tissues.

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