Ineffective Airway Clearance r/t retained secretions

Nursing Cues Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Explanation

S>  Ineffective Airway The underlying After 4 hours of -Assessed and -Changes may indicate Goal partially met.
Clearance related pathology in asthma nursing intervention, monitored respiratory progression of After 4 hours of
O>dyspnea to retained is reversible and the patient will be able rate, depth and rhythm. respiratory compromise. nursing intervention,
secretions diffuse airway to maintain a patent patient’s airway is
> productive inflammation. The airway. - Auscultated chest, - Checks inflow through patent as evidenced by
cough with inflammation leads to noted presence of the airway and the a normal respiratory
white sputum obstruction from the adventitious breath presence or absence of rate of 57cpm and
following: swelling sounds and presence of fluid mucus obstruction. absence of dyspnea
> wheezes in both of the membranes secretions. but still has productive
lung fields that line the airways cough and wheezes.
(mucosal edema), - Encouraged prone and - Prevents stasis of
> use of reducing the airway upright positioning secretions and
accessory diameter; contraction especially when feeding promotes lung
muscles of the bronchial expansion.
smooth muscle that
>increased encircles the airways - Encouraged to -To loosen secretions.
respiratory rate (bronchospasm), increase fluid intake.
of 62 cpm causing further
narrowing; and - Imparted health - Promotes SO’s
increased mucus teachings to SO such understanding and
production, which as importance of participation in care
diminishes airway positioning and
size and may entirely increasing fluid intake
plug the bronchi. The
bronchial muscles - Ensured medication -Enhances clearance of
and mucus glands administration as secretions from airway.
enlarge; thick, ordered. Nebulized with
tenacious sputum is Salbutamol as ordered.
produced; and the
alveoili hyperinflate. - Performed chest -Optimizes results of
physiotherapy after treatment.
treatment.