INEFFECTIVE AIRWAY CLEARANCE Nursing Care Plan

Mr. Andrew was doing wooden wall renovations in their garage. Mr. Andrew's nail gun was suddenly failed to function and he discovered that two nails was stuck in it. While he was trying to fix it, a nail suddenly came out of it and drove piercingly to his throat. Her daughter saw help and called for help. Mr. Andrew was still conscious but really hard to breathe and he felt the blood piling up inside his throat.

ASSESSMENT

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

Objectives: 
Mr. Andrew, the patient is pale in appearance, and he been having difficulty in vocalizing. He experience restlessness, difficult of breathing and positive in productive cough. Mr. Andrew cannot find comfort, irritable, and cannot stay still. Mr. Andrew's vital signs were taken and noted as follows: Body temperature was 36.8 degrees Celsius, blood pressure was 120/80 mmHg, respiratory rate was 32 cycles per minute, pulse rate was 96 beats per minute. Only pulse rate was at normal range, body temperature and respiratory rate were above normal while client's blood pressure was 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 Mr. Andrew's cough, gag reflex and his swallowing ability to determine ability to protect his own airway. Gag reflex is the natural contraction at the back of his throat and naturally urges him to vomit when a large object is touching his inner roof of the mouth. Assist with appropriate testing such as pulmonary function of sleep studies to identify causative of precipitating factors. Monitor his breath sounds to check for the accumulation of secretions or respiratory blisters. By using the process of auscultation, you can monitor Mr. Andrew's breath sounds. 

- Insert oral airway using correct size for adult like Mr. Andrew, this is to maintain anatomic position of tongue and natural airway especially when his tongue or laryngeal edema or thick secretions may block his airway. Suction the patient's nose or mouth as necessary to clear airway when excessive or vicious secretions are blocking the airway of the patient and are unable to swallow. Elevate the head of the bed to decrease pressure on his diaphragm and to enhance his drainage secretions. 

- Encourage Mr. Andrew of 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 his viscous secretions and improve his secretion clearance. Monitor for signs and symptoms of congestive heart failure like crackles, edema, weight gain when client is at risk. Perform the patient 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 were disappeared.

For more samples of nursing care plan you are free to check it out in our NCP LIST page.