Question

CARE PLAN FOR INEFFECTIVE AIRWAYS CLEARANCE

Answer 1

Ans) Assessment included in nursing intervention:

Nursing diagnosis:

Ineffective Airway Clearance: related to

• Airway spasm/asthma
• Copious and tenacious tracheobronchial secretions

Expected goal:

• Patient will maintain clear, open airways as evidence by normal breath sounds, normal rate and depth of respirations, and ability to effectively cough up secretions after treatments and deep breaths.
• Patient will demonstrate increased air exchange.

Nursing intervention with rationale:

• Assess airway for patency.- Provides baseline data to plan care.
• Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing- A change in the usual respiration may mean respiratory compromise. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction.
• Provide propped up position: Facilitates breathing
• Review patient’s understanding of disease process.- Patient teaching will vary depending on the acute or chronic disease condition as well as the patient’s cognitive level.
• Teach the patient the proper ways of coughing and breathing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession)- The most convenient way to remove most secretions is coughing. So it is necessary to assist the patient during this activity. Deep breathing, on the other hand, promotes oxygenation before controlled coughing
• Encourage patient to increase fluid intake to 3 liters per day within the limits of cardiac reserve and renal function- Fluids help minimize mucosal drying and maximize ciliary action to move secretions
• Administer Medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects- promote clearance of airway secretions and may reduce airway resistance
• Coordinate with a respiratory therapist for chest physiotherapy and nebulizer management as indicated- Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions from smaller airways that cannot be eliminated by means of coughing or suctioning.