8/13/2019 NCP- INEFFECTIVE AIRWAY CLEARANCE PEDIA.docx

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ASSESSMENT

NURSING

DIAGNOSISINFERENCE PLANNING

NURSING

INTERVENTIONRATIONALE EVALUATION

Subjective:Nahihirapang

huminga ang anakko at may

kontingplema sayakung umuubosiya. Asverbalized by thepatients mother.

Objective:BP: 60/40PR: 167 bpmTemp: 37.2CRR: 71 cpm

Tachypneac

Dyspneac

Tachycardiac

With DOB andcrackel sounds onleft lung

Change inrespiratory rateand rhythm

With series ofproductive cough

Ineffective airwayclearance relatedto excessivemucus secondary

to pneunonia

Pneumonia isinflammation of theterminal airwaysand alveoli caused

by acute infectionby various agents.Pneumonia can bedivided into threegroups: communityacquired, hospitalor nursing homeacquired(nosocomial), andpneumonia in animmunocompromis

ed person.Causesinclude bacteria(Streptococcus,Staphylococcus,Haemophilusinfluenzae,Klebsiella,Legionella).Community

AcquiredPneumonia (CAD)

is adisease inwhich individualswho have notrecentlybeenhospitalizeddevelopaninfection ofthelungs.It is anacute inflammatorycondition thatsresult from

aspiration of

After 8 hours ofnursing intervention the patientwould be able to:

Maintain airwaypatency

Demonstratereduction ofcongestion withbreath soundsclear, respirationsnoiseless, improveoxygen exchange.

Display absence oftachypnea,dyspnea andtachycardia

Independent:Elevate head ofthe bed/ changeposition every 2

hours and prn.

Monitor v/s signs

especiallyrespiratory rate,note for respiratorydistress

Monitorrespirations andbreath sounds,noting rate andsounds

Evaluates clientscough or gagreflex andswallowing ability

Suctionnaso/tracheal/oralprn

To take advantageof gravitydecreasing

pressure on thediaphragm andenhancingdrainageof/ventilation ofdifferent lungsegment

To evaluate

degree ofcompromise

Indicatives ofrespiratory distressand/oraccumulation ofsecretions

To determineability to protectown airway

To clear airwaywhen excessive orviscous secretionsare blockingairway or client is

unable to swallow

After 8 hours ofnursing intervention the patient:

Maintained airwaypatency

Demonstratedreduction ofcongestion withbreath soundsclear, respirationsnoiseless, improveoxygen exchange.

Displayed absenceof tachypnea,dyspnea andtachycardia

The goal is met

http://en.wikipedia.org/wiki/Diseasehttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Infectionhttp://en.wikipedia.org/wiki/Hospitalhttp://en.wikipedia.org/wiki/Disease

8/13/2019 NCP- INEFFECTIVE AIRWAY CLEARANCE PEDIA.docx

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oropharyngealsecretions orstomach contentsin the lungs.

Standby Oxygenat bedside

Insert oral airway

as needed

Advice CPT tomother

Increase fluidintake to at least2000ml/day withincardiac tolerance

Dependent:Give

expectorants/bronchodolators asordered

or cougheffectively

For emergency

To maintainanatomic positionof tongue andnatural airway,especially whentongue/ laryngealedema or thicksecretions mayblock airway

Helps on secretion

of excessivemucus

Hydration can helpliquefy viscoussecretions andimprove secretionclearance

Aids in

reduction ofbronchospasm andmobilization ofsecretions.