Pediatric Nursing Care Plan Kelly Shumway

Priority Nursing Diagnosis: Ineffective airway clearance related to inflammation of the lung tissue as evidenced by
auscultation of wheezing and rhonchi in the lungs, cough, lethargy, pulse oximetry reading of 89%.
Goal Patient will have an improvement in airway clearance.
Outcome Criteria
1. Patient will have a
decrease in amount of
secretions within 5 days.
2. Patient will be able to
demonstrate correct
technique to cough within 2
days.
3. Patient will effectively
cough up secretions within 2
days.
4. Patient will exhibit thinner
secretions within 3 days.
5. Patient will tolerate an
increase in length of activity
by at least 10 minutes within
4 days.
6. Patient will exhibit
decreased episodes of
wheezing within 3 days.
7. Patients baseline vitals will
be within range of
_______________ within 4 days.

Interventions
1. Assess secretions q shift.
2. Teach coughing & breathing
techniques q shift.
3. Assess cough for effectiveness &
productivity q 4 hour.
4. Encourage an increase in fluid
intake q 2 hour.
5. Plan activity and rest to
maximize patients energy q shift.
6. Administer nebulizer medications
as ordered q shift.
7. Assess VS q shift.
8. Auscultate lung sounds q 4
hours.
9. Monitor oxygen saturations q 4
hours.
10. Assess nutritional status q shift.
11. Assess changes in HR, BP &
temperature q 4 hours.
12. Assess respirations quality,
rate, and rhythm q 4 hours.
13. Teach caregivers suctioning
techniques q shift.

Scientific Rationale
1. Secretions increase
airway resistance & work of
breathing. Discoloration of
secretions can indicate the
presence of an infection.
(NCP Pg. 13 Gulanick)
2. Coughing helps to
facilitate clearance of
secretions & prevent
telecasts. Dyspnea may be
decreased with pursed lip
breathing or diaphragmatic
breathing. (NCP Pg. 15
Gulanick)
3. Coughing is the best way
to remove secretions from
the airway. Ineffective
coughing may compromise
airway clearance. (NCP Pg.
13 Gulanick)
4. Intake of fluids helps to
remove secretions. Also it
reduces viscosity of

Evaluation
1. Patient met goal.
2. Patient met goal.
3. Patient met goal.
4. Patient partially met goal. Patient
slowly increased the amount of fluids
taken in within 3 days from 3 oz. q 3
hours to 9 oz. q 3 hours.
5. Patient met goal.
6. Patient met goal.
7. Patient partially met goal. Patient
was able to maintain afebrile
temperature, HR 132, R 48, BP
118/60, Oxygen Sat 92%
8. Patient partially met goal. Patient
had a decreased rhonchi upon
auscultation.
9. Patient met goal.
10. Patient met goal.
11. Patient met goal.
12. Patient partially met goal. Patient
maintained normal respiration rate,
quality and rhythm upon mild
activity.

8. Patient will exhibit clear

open airway within 7 days.
9. Patient will maintain
oxygen saturations of 90% or
better on room air within 2
days.
10. Patient will regain
nutritional status within 5
days
11. Patient will not exhibit
tachycardia within 4 days.
12. Patient will exhibit
regular rhythm, depth and
rate of respirations in
moderate activity within 5
days.
13. Patients family will
effectively be able to
facilitate removal of
secretions with suctioning
within 2 days.
14. Patient will have clear
lungs sounds on auscultation
within 8 days.

14. Administer chest physiotherapy

per MD order.

secretions. Reduced
viscosity of secretions
makes it easier for patient
to mobilize secretions with
coughing.
(NCP Pg. 14 Gulanick)
5. Fatigue is common with
an increase in metabolic
rate and oxygen
requirements that are
needed. (NCP Pg. 36
Gulanick)
6. Nebulizer treatments are
used to thin secretions and
help with removal of
secretions.
(NCP Pg. 14 Gulanick)
7. Obtaining & monitoring
patients VS help to monitor
the health status & allows
significant changes to be
addressed in a timely
fashion to benefit patient.
(NCP Pg. 13 Gulanick)
8. When fluid or mucus
accumulates in lungs
abnormal breath sounds
can be heard and indicate
an obstruction.
(NCP Pg. 12 Gulanick)
9. Monitoring oxygen
saturations is a useful tool

13. Patients family met goal.

14. Patient partially met goal. Patient
exhibited decrease in wheezing and
rhonchi present upon auscultation.

to detect changes in
oxygenation. Oxygen levels
should be minimum 90%.
(NCP Pg. 13 & 35 Gulanick)
10. Malnutrition can result
during premature
development of respiratory
failure. Maintaining
nutritional status helps to
maintain respiratory mass
& strength maintaining
muscle function. (NCP Pg.
84 Gulanick)
11. Tachycardia &
hypertension can be
related to increased work
of breathing or hypoxia.
Fever may develop in
response to retained
secretions or atlectasis or
may be a manifestation of
an infections or
inflammatory process.
(NCP Pg. 13 Gulanick)
12. Abnormalities in
respiration rate and
qualities can indicate
respiratory compromise. An
increase in respiratory rate
and rhythm may be a
compensatory response to

airway obstruction. (NCP

Pg. 13 Gulanick)
13. Instruction promotes
safe and effective removal
of secretions from the
airway.
(NCP Pg. 15 Gulanick)
14. Chest physiotherapy
loosens and mobilizes
secretions.
(NCP Pg. 14 Gulanick)

Works Cited
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes (8th ed.).
Philadelphia, PA: Elsevier Mosby.