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INEFFECTIVE AIRWAY CLEARANCE Nursing Care Plan

Ineffective airway clearance is a state when an individual is cannot clear secretions or obstructions in the respiratory tract. Below is an example of nursing care plan for patients with ineffective airway clearance.

You can download the table version of this nursing care plan here. Just wait for the ad and continue to download.

ASSESSMENT
Subjective:
" I can't breath that much, something's obstructing inside my throat." as verbalized by the patient.

Objectives:
The patient is pale in appearance, and having difficulty in vocalizing. The patient experience restlessness, difficult of breathing and positive in productive cough. Restlessness is a state when you can not find comfort, irritable, and cannot stay still. Vital signs are taken and noted as follows: Body temperature is 36.8 degrees Celcius, blood pressure is 120/80 mmHg, respiratory rate is 32 cycles per minute, pulse rate is 96 beats per minute. Only pulse rate is at normal range, body temperature and respiratory rate are above normal while client's blood pressure is considered pre-hypertension.

DIAGNOSIS
Ineffective airway clearance related to difficulty in breathing as evidenced by restlessness and difficulty of vocalizing. (Difficulty in breathing or also known as dyspnea and difficulty in vocalizing here were caused by obstruction in the respiratory tract.

PLANNING
After 2 hours of nursing intervention, airway patency will be maintained and signs of dyspnea will disappear. (Why 2 hours? We need to manage the breathing problem as soon as possible because it can cause serious harm or damage to the patient.)

INTERVENTIONS
Evaluate client's cough, gag reflex and swallowing ability to determine ability to protect his/her own airway. Gag reflex is the natural contraction at the back of the throat and naturally urges vomiting when a too large object is touching the inner roof of the mouth. Assist with appropriate testing such as pulmonary function of sleep studies to identify causative of precipitating factors. Monitor breath sounds to check for the accumulation of secretions or respiratory blisters. By using the process of auscultation, you can monitor the patient's breath sounds.

Insert oral airway using correct size for adult or child when needed, this is to maintain anatomic position of tongue and natural airway especially when tongue or laryngeal edema or thick secretions may block airway. Suction the nose or mouth as necessary to clear airway when excessive or vicious secretions are blocking the airway of the client is unable to swallow. Elevate the head of the bed to decrease pressure on the diaphragm and to enhance the drainage secretions.
Encourage deep breathing and coughing exercises, splint chest to maximize effort. Administer analgesics to improve cough when pain is inhibiting effort but be cautious because over medication can depress respiration and cough effort. Give expectorants or bronchodilators as ordered. Increased fluids intake to at least 2000 mL/day within cardiac tolerance may require IV in acutely ill, hospitalized client. Encourage warm versus cold liquids as appropriate. Provide supplemental humidification, if needed. Hydration can help liquefy viscous secretions and improve secretion clearance. Monitor for signs and symptoms of congestive heart failure like crackles, edema, weight gain when client is at risk. Perform client with postural drainage and percussion as indicated if not contraindicated by condition, such as asthma.

EVALUATION
After 2 hours of nursing intervention the patient's airway patency is clear and maintained, and signs of dyspnea was disappeared.

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