Nursing Care Plan

CUES NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

GOALS and OBJECTIVES GOAL: After 8hrs. The client will be able to maintain airway patency. OBJECTIVE:

NURSING INTERVENTIO NS

RATIONALE

EVALUATION Effectiveness: Was the client able to expectorate clear secretions? Yes__

Ineffective Airway Clearance related to excessive mucus

In children the airway is smaller and subject to considerable narrowing from edematous mucus membranes and increased production of secretions. (Wongs Nursing Care of Infants and Children 8th ed. P 1315) Sputum production is the reaction of the lungs to any constantly recurring irritant. It may also be associated

After 1 hour of Nursing Interventions the client will be able to expectorate clear secretions.

Monitor respirations and breathe sounds.

Indicative of No__ respiratory distress and/ Why? or accumulation Was the client of secretions. able to verbalize To remove retained secretions in the lungs. To liquefy secretions and improve secretion clearance. understanding of causes and therapeutic management? Yes__ No__ Why? Efficiency:

Provided back tapping.

Encouraged increase fluid intake.

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with a nasal discharge. (Brunner and Suddarths Medical Surgical Nursing 12th ed. p. 496) Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Were the

After 30mins of Nursing Interventions the client will be able to verbalize understandin g of causes and therapeutic management.

Provided information about the necessity of raising and expectorating secretions versus swallowing them.

human To report changes in resources, color and materials and amount in the event that time used medical economically? intervention may be Yes__ needed to No__ treat infection. Why? To prevent cross contaminatio n. Appropriateness: Were the interventions suitable to clients

Advise client to use hanky or cover mouth when coughing

After 30mins of Nursing Intervention the client will be able demonstrate different therapeutic management to maintain airway clearance.

Demonstrate effective coughing. Demonstrate Deep Breathing. Encourage client to avoid

To help remove and expectorate secretions. To aid in clearing the airway. This may aggravate

situation? Yes__ No__ Why?

Were the setting and

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irritants such as smoke, dust, smog, and perfumes. patient condition. time table interventions realistic to clients situation? Yes__ No__ Why? Acceptability: Were the interventions accepted by the patient (without any signs of rejection from the patient)? Yes__ No__ Why? Adequacy: Was the

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number of interventions sufficient to meet the desired goal and objectives? Yes__ No__ Why?