NURSING CARE PLAN #2

ASSESSMENT

Subjective:
- Gaduha-duha siya
magpasuction kay
saktan siya. As
verbalized by
Informant XY

DIAGNOSIS
(NANDABASED)
Ineffective Airway
Clearance r/t
excessive mucus

PLANNING

Short Term:
After 45 minutes of
nursing interventions,
patient will be able to:
1. Maintain patent
airway.
2. Clear secretions
readily.

Objective:
- (+) crackles
- (+) Retained
secretions
- (+) NGT tube

Long Term:
After 8 hours of nursing
interventions, the
patient will be able to:
1. Demonstrate
absence of mucus
secretion with
breath sounds
clear respiratory
airways.

IMPLEMENTATION

Independent:
1. Establish rapport.
2. Check airway for patency.
3. Auscultate breath sounds.
4. Check for changes in vital
signs and temperature.
5. Monitor blood gas values
and pulse oxygen saturation
levels as available.
6. Position client to optimize
respiration (e.g., head of
bed elevated 45 degrees
and repositioned at least
every 2 hours).
7. Maintain a fluid intake of at
least 2500 ml / day unless
contraindicated.
8. Encourage in deepbreathing and directedcoughing exercises; teach
and reinforce breathing and
coughing while splinting
incision.
9. Clean secretions from the
mouth and trachea, suction
if necessary.

Collaborative/Depende

RATIONALE

1. To gain clients and

significant others trust.
2. Maintaining patent
airway is always the first
priority.
3. Breath sounds are
normally clear or
scattered fine crackles
at bases, which clear
with deep breathing.
4. Increased work of
breathing can lead to
tachycardia and
hypertension. In
response to retained
secretions/atelectasis,
fever may develop.
5. Normal blood gas
values are a PO2 of 80
to 100 mm Hg and a
PCO2 of 35 to 45 mm
Hg. An oxygen
saturation of less than
90% indicates problems
with oxygenation.
6. An upright position
allows for maximal air
exchange and lung
expansion; lying flat

EVALUATION
(ACTUAL)

Short Term:
Goals met.
Patients airway
patency
maintained. Patient
refused to be
suctioned at first.

Long Term:
Goals met. Patient
demonstrated
absence of mucus
and have clear
breath sounds.

nt:
10. Administer medications
such as bronchodilators or
inhaled steroids as ordered.
Watch for side effects such
as tachycardia or anxiety
with bronchodilators,
inflamed pharynx with
inhaled steroids.
11. Administer oxygen as
ordered.

causes abdominal
organs to shift toward
the chest, which crowds
the lungs and makes it
more difficult to breathe.
7. Helps thin the
secretions so easily
removed.
8. To maximize cough
effort, lung expansion,
and drainage, and to
reduce pain impairment.
9. To prevent
obstruction/aspiration.
Suction done when
patients are unable to
remove secretions.
10. Bronchodilators
decrease airway
resistance secondary to
bronchoconstriction.
11. Oxygen has been
shown to correct
hypoxemia, which can
be caused by retained
respiratory secretions.