Nursingcrib.com Nursing Care Plan Ineffective Airway Clearance (bronchi)

NCP I

Cues

Nursing Diagnosis

Inference

Subjective ◈ “Nahihirapan akong huminga dahil sa kakaubo ko,” as verbalized. Objective ◈ pale in appearance

◈ Ineffective Airway Clearance r/t secretions in the bronchi

Irritant (inhalation)

inflammatory response

increase production of secretions

◈ dyspnea

Objective

Nursing Intervention

Rationale

Short Term Goal

Independent

◈ After 4 hours of nursing intervention, airway patency will be maintained, secretions will be readily expectorated and there will be signs of reduction in congestion.

◈ Vital signs monitored and recorded.

◈ This is for baseline comparison.

◈ Assisted in semifowler’s position.

◈ Proper positioning helps in draining secretions.

◈ Encouraged deep breathing exercise.

◈ This will promote proper lung expansion.

airway constriction ◈ (+) use of accessory muscles when breathing

Dependent dyspnea

◈ (+) productive cough

◈ Administered prescribed medications.

◈ Prescribed meds such as bronchodilators helps in aiding effective airway clearance.

◈ Provided supplemental humidification via use of nebulizer.

◈ Nebulization helps in liquefying secretions for better and faster expectorating the secretions.

◈ RR=24cpm Reference: Understanding Pathophysiology, Huether

Evaluation

◈After 4 hours of nursing intervention, the goal is met through maintenance of airway patency and reduction in congestion.

NCP II

Cues

Nursing Diagnosis

Inference

◈ Hyperthermia r/t inflammatory response

Irritant (microbial)

Subjective ◈ “Nilalamig ako at medyo masakit ang ulo ko,” as verbalized.

inflammatory response

Objective ◈ weak looking ◈ skin warm to touch ◈ T = 38.5°C RR = 24cpm

Objective

Nursing Intervention

Short Term Goal

Independent

◈ After 1 hour of nursing intervention, body temperature will be maintained within the normal range.

◈ Vital signs monitored and recorded. ◈ Provided tepid sponge bath.

Rationale

◈ This is for baseline comparison. ◈ TSB will help in lowering the patient’s temperature.

tissue injury ◈ Advised to increase fluid intake.

◈ Increase in oral fluids will prevent dehydration.

◈ Instructed to maintain bedrest.

◈ This will help in reducing metabolic demands and oxygen consumption.

◈ Encouraged deep breathing exercise.

◈ This will promote proper lung expansion.

vascular response

hyperemia (heat, redness, pain)

Reference: Mastering Fundamentals of Nursing, Udan

Dependent ◈ Administered prescribed medications.

◈ Prescribed meds such as paracetamol help in reducing fever by direct action on hypothalamus heatregulating center with consequent peripheral vasodilation, sweating, and dissipation of heat..

Evaluation

◈After 1 hour of nursing intervention, the goal is met through the maintenance of body temperature within the normal range.