NURSING CARE PLAN NO.

1 Problem Identified Date Identified Date Evaluated Ineffective Airway Clearance January 21, 2012 January 21, 2012 Dyspneic Diminished/adventitious breath sounds (rales, crackles, and rhonchi) Cough ineffective Changes in respiratory rate or rhythm Shortness of breath Pallor Use of accessory muscles was noted upon respiration With the following abnormal Vital Signs taken as follows: PR- 170 bpm RR- 67 BPM O2 Sat-87% Ineffective airway clearance related to retained secretions as manifested by difficulty of breathing and increased respiratory rate. Within 4 hours of client-centered nursing interventions, the patient and the significant others will be able to demonstrate behaviors to improve or maintain clear airway. Independent 1. Monitor vital signs, respirations and breath sounds, noting rate and sounds. - This is indicative of respiratory distress and/or accumulation of retained secretions. 2. Evaluate clients cough/gag reflex and swallowing ability. - To determine ability to protect own

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airway. Assess respiratory movements and use of accessory muscles. - use of accessory muscles to breathe indicates an abnormal increase in work of breathing. Observe sputum color, amount, and odor and report significant changes. - a sign of infection is discolored sputum and odor may be present. Auscultate lung sounds, noting areas of decreased ventilation and presence of adventitious sounds - Bronchial lung sounds are commonly heard over areas of lung density or consolidation. Crackles are heard when fluid is present. Monitor oxygen saturation. - Hypoxemia may result from impaired gas exchange from buildup of secretions. Monitor chest x-ray reports. - These determine progression of disease process. Position head appropriate for age/condition. - To open or maintain open airway in atrest or compromised individual. Elevate the head of bed/ change position every 2 hours and prn. - To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ ventilation to different lung segments. Perform/assist client with postural drainage and percussion OR chest-tapping as indicated if not contraindicated by condition, such as asthma. - To mobilize and loosen secretions in the lungs and promote expectoration. Encourage patient and SO to maintain high back rest. - To promote maximum lung expansion. Encourage deep breathing and coughing exercises. - To maximize effort thus improving productivity of the cough. Encourage to maintain adequate hydration

- Fluids are lost by diaphoresis, fever, and tachypnea and are needed to aid in the mobilization and liquifying of secretions. 14. Instruct SO to provide oral care. - Secretions from pneumonia are often foul tasting and smelling. Providing oral care may decrease nausea and vomiting associated with the taste of secretion. Dependent 1. Suction naso/tracheal/oral prn. - To clear airway when excessive or viscous secretions are blocking airway or client is unable to swallow or cough effectively. 2. Administer inhaled bronchodilatorsSalbutamol (Ventolin) 2.5mg (1neb) BID to open airway and decrease inflammation. - It relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. 3. Administer analgesicsParacetamol 120mg/5ml 7.5ml q 4hrs P.O. PRN to improve cough when pain is inhibiting effort. (CAUTION: Overmedication can depress respirations and cough effort.) - To improve cough when pain is inhibiting effort. After 4 hours of nursing intervention, the patient was able to demonstrate behaviors to improve oxygenation and clear airway as evidenced by expectorating secretions and improved oxygen saturation of 95%.

Evaluation