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Nursing Diagnosis

Objectives

Nursing Interventions

Nursing Diagnosis:
Ineffective Airway
Clearance

Goals/ Objectives:
Short term goal:
Client will demonstrate
signs of patent airway
and adequate oxygen
exchange within 3 days.
Long term goal:
Client will demonstrate
behaviours to improve
or maintain airway
clearance and identify
potential complications
and initiate appropriate
actions.

Nursing Actions

Possible Etiologies:
(Related to)
Bronchospasm
Increased production
of secretions; retained
secretions; thick,
viscous secretions
Decreased energy/
fatigue
Defining characteristics:
(Evidenced by)
Statement of difficulty
in breathing
Feeling of chest
constriction
Changes in depth/ rate
of respiration;
tachypnea
Tachycardia
Use of accessory
muscles or marked
respiratory effort
Abnormal breath
sound, inspiratory and
expiratory wheezing
Cough (persistent),
without sputum
production
Prolonged expiration

1. Assess respiratory status


every hour during acute
phase: lung sounds,
respiratory rate and depth,
presence and severity of
wheezing, breathing pattern,
use of accessory muscles.
2. Assist patient to assume to
comfortable position, i.e.
elevate head of bed, have
client lean on over bed table
or sit on the edge of bed.
3. Keep environmental
pollution to a minimum
according to individual
situation.
4. Encourage and assist
abdominal and pursed lip
breathing exercises.
5. Increase fluid intake to
3000ml/ day within cardiac
tolerance.
6. Provide warm liquids and
recommend intake of fluids
between meals, instead of
during meals.
7. Administer medications as
indicated.
8. Monitor side effects of
bronchodilator (tremors/
tachycardia).
9. Provide supplemental
humidification, e.g.,
neutralizer in respiratory

Rationale

1. Some degree in
bronchospasm is present
with obstruction in
airway and may be
manifested with
wheezing or absent
breath sounds in severe
asthma. Tachypnea is
usually present to some
degree and respiratory
dysfunction is variable
depending on underlying
process such as allergic
reaction.
2. Elevation of head of the
bed facilitates respiratory
function by use of
gravity, however client in
distress may seek
position that most eases
breathing.
3. Precipitators of allergic
type of respiratory
reactions that can trigger
or exacerbate onset of
acute episode.
4. Provides some means to
cope with or control
dyspnea and reduce air
trapping.
5. Hydration helps thin
secretions, facilitating
expectoration and using
warm liquids may
decrease bronchospasm.

Evaluation

Outcome
Criteria:
Client will
verbalize
reduction or
absence in
difficulty in
breathing and
feeling of chest
constriction,
respiration and
cardiac rate
within normal
range, absence or
reduction of
inspiratory and
expiratory
wheezing, and
ability to resume
to activities.
Client will be
able to identify
and avoid
potential
allergens or
stimuli that would
trigger asthma
attack and be able
to handle
symptoms if
recurrence comes,

treatments.
10. Monitor ABGs, pulse
oximetry, chest x- ray.

6. Fluids during meals can


increase gastric
distension and pressure
on the diaphragm.
7. Anticholinergic
medications are the first
line drugs for clients with
this condition.
8. Humidity helps reduce
viscosity of secretions,
facilitating expectoration
and may.
9. Breathing exercises help
enhance diffusion,
nebulizer medications
can reduce
bronchospasm and
stimulate expectoration.
10. Establishes baseline for
monitoring progression/
regression of disease
process.

prompt follow up
checkup and to
always bring or
have the
prescribed
medication/s on
hand in case
asthma occurs.