Nursing Care Plan

DIAGNOSIS PLANNING INTERVENTION RATIONALE

MENT

EVAL

irapan nga

Ineffective airway clearance related to increase in mucous secretion secondary to pulmonary infection

Short term goal: After the nursing interventions, the client will be able to: 1 Sustain respiratory rate within normal range: RR = 1220 cpm. 5 Assessed respiratory rate. 12 Provides a basis for evaluating adequacy of ventilation.

After th interven client w display of airwa manifes

ormal unds: es.

1 Cl respirat is within range: R bpm.

pnea; essory or n:

2 Allay restless-ness.

less signs: Long term goal: During the clients stay home she will be able to maintain patent airway as evidenced by: 1 Normal respiration as evidenced by absence of dyspnea and

6 Noted chest movement; use of accessory 13 Use of muscles during accessory respiration. muscles of respiration may occur in response to ineffective ventilation.

2 Se decreas

3 Cl restless alleviat remaine

0/90

5c cpm bpm

7 Auscultated breath sounds; noted areas with presence of adventitious sounds.

14 Crackles indicate accumulation of secretions and inability to clear airways.

8 Documented respiratory 2 Normal secretions: breathing pattern: RR = 12- character and amount of 20 cpm. sputum. 3 Absence of bronchial secretions. 4 Allay restless-ness 9 Maintained patient on moderate high back rest. 10 Checked for obstructions: accumulation of secretions. 11 Take medications as ordered by the physician.

adventitious breath sounds.

15 Expectorations may be different when secretions are very thick. 16 Positioning helps maximize lung expansion. 17 To maintain adequate airway patency.