This nursing care plan addresses a patient experiencing ineffective airway clearance due to retained lung secretions. The plan includes independent nursing interventions like monitoring breathing, positioning the patient, and encouraging deep breathing. Dependent interventions include respiratory therapy treatments and regulating oxygen tank use. The short term goal is for the patient to maintain an open airway, cough up secretions, and perform deep breathing exercises within 8 hours. The long term goal is for the patient to report no congestion with clear breathing sounds and improved oxygen exchange within 3 days.
This nursing care plan addresses a patient experiencing ineffective airway clearance due to retained lung secretions. The plan includes independent nursing interventions like monitoring breathing, positioning the patient, and encouraging deep breathing. Dependent interventions include respiratory therapy treatments and regulating oxygen tank use. The short term goal is for the patient to maintain an open airway, cough up secretions, and perform deep breathing exercises within 8 hours. The long term goal is for the patient to report no congestion with clear breathing sounds and improved oxygen exchange within 3 days.
This nursing care plan addresses a patient experiencing ineffective airway clearance due to retained lung secretions. The plan includes independent nursing interventions like monitoring breathing, positioning the patient, and encouraging deep breathing. Dependent interventions include respiratory therapy treatments and regulating oxygen tank use. The short term goal is for the patient to maintain an open airway, cough up secretions, and perform deep breathing exercises within 8 hours. The long term goal is for the patient to report no congestion with clear breathing sounds and improved oxygen exchange within 3 days.
Objective: Dyspnea Dysphagia Dysarthria Irritable and restless Coughing reflex very minimal Whitish to yellowish and very thick phlegm Crackles Weak breath sounds Effortful breathing With 0 2 tank dependence : regulated 8-10lpm Skin is pale and cold Capillary refill of 4secs. Left and right ear are not responsive to verbal approach/ sound stimulation
BP: 110/60 P: 120 RR: 30 T: 36.7
Ineffective Airway Clearance r/t retained lung secretions as manifested by difficulty of breathing Short term: After 8 hours of nursing interventions the client will be able to: Maintain patent airway and use of oxygen mask. Expectorate secretions readily Demonstrate deep breathing exercise
Long Term: After 3 days of nursing interventions client will be able to: Reports absence of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange
INDEPENDENT : 1. Monitor rate, rhythm, depth, and effort of respirations.
2. Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.
3. Monitor for increased restlessness, anxiety, and air hunger.
4. Assisted client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed.
5. Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds.
6. Encourage her to take several deep breaths.
7. Promote systemic fluid hydration, as appropriate.
DEPENDENT : 1. Institute respiratory therapy treatments (e.g., nebulizer) as needed.
2. Regulate O 2 tank as ordereded by the doctor
INDEPENDENT : 1. Provides a basis for evaluating adequacy of ventilation.
2. Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation.
3. These clinical manifestations would be early indicators of hypoxia.
4. Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.
5. As fluid and mucus accumulate, abnormal breath sounds can be heard including crackles and diminished breath sounds owing to fluid- filled air spaces and diminished lung volume.
6. Deep breathing promotes oxygenation before controlled coughing.
7. Adequate fluid intake enhances liquefaction of pulmonary secretions and facilitates expectoration of mucus.
DEPENDENT 1. A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions.
2. Used to correct and prevent worsening of hypoxemia, improve survival, and quality of life. Supplemental oxygen can be provided during exacerbations only, or as a long-term therapy. Short term: After 8 hours of nursing interventions the client was be able to: Maintain patent airway and use of oxygen mask. Expectorate secretions readily Demonstrate deep breathing exercise
Long Term: After 3 days of nursing interventions client was be able to: Reports absence of congestion with breath sounds clear, respiration noiseless, improved oxygen exchange