NCP for Ineffective Airway Clearance

ASSESSMENT
SUBJECTIVE:
The wife
complains of
difficulty
breathing of the
patient,
Nahihirapan
siya minsan
huminga kasi
may plema sya
palagi at ang
hirap minsan
ilabas, as
verbalized.
OBJECTIVE:
- Difficulty of
breathing
noted, rapid
rise of the
chest
- Mucus
accumulation
on airway
passage
- Gurgling
sound on
throat
- Productive
cough
- Crackles
noted upon
auscultation

DIAGNOSIS
Ineffective
Airway
Clearance
related to
retained
secretion

ANALYSIS

PLANNING

Inflammatory
OBJECTIVE:
response causes Achieve airway
tissue edema
clearance
and exudate
formation in the SHORT TERM
lungs.
GOAL:
Immobility
Within 2 hours of
causes the
rendering
secretions to
nursing care, the
accumulate in
patient will be
the areas and
able to:
difficult to be
- Perform
expectorated
effective
once secretions
coughing to
are in the
expectorate
bronchial and
mucus
tracheal area.
secretions
Eliminate
Saliva can also
mucus
accumulate in
accumulation
the esophagus
through
which also
expectoration
allows blockage
and proper
to the airway
use of
passage.
suctioning
devices
- Maintain
airway
patency
- Relieve
breathing
difficulties
- Achieve a

NURSING
INTERVENTION
1. Monitor vital
signs
2. Assess
respiratory
rate and
characteristi
cs
3. Auscultate
lung sounds
4. Elevate HOB
up to 30
degree and
assist
patient in a
semi-fowlers
position
5. Perform back
clapping,
back
cupping and
chest
tapping
6. Encourage
patient to
expectorate
7. Assist
patient in a
side-lying
position
8. Suction as
needed.
9. Clean inner
cannula of
endotracheal

RATIONALE

EVALUATION

1. To obtain
baseline
measuremen
t
2. To note
patients
condition
3. Crackles are
heard due to
presence of
fluid
accumulation
4. To promote
lung
expansion
and aid in
breathing
technique
5. To loosen
secretions
and aid in
expectoratio
n
6. To minimize
the use of
suctioning
devices
7. To promote
lung
expansion
and mobilize
secretions
8. An
intervention

SHORT and
LONG TERM
GOALS:
After 4 hours of
nursing care,
the goal is
partially met.
Airway
clearance was
achieved upon
intervention.
However,
secretions are
not fully
eliminated as
patient still
experiences
gurgling sounds
on throat after
some time.
Nursing
intervention is
continued with
some
modifications of
it according to
the patients
current
condition.

of bronchial
area
Difficulty of
expectoratio
n
Presence of
artificial
airway such
as,
endotracheal
tube
Restless
Complains of
discomfort
RR noted
22cpm

decreased in
RR noted
<23cpm
LONG TERM
GOAL:
After 4 hours of
rendering
nursing care, the
patient will be
able to:
- Eliminate
retained
secretions
- Achieve
comfort
and rest

tube
10.Assist in
ROM
exercise and
position
changes
11.Promote rest
and comfort
by
elimination
of secretions
through
suction of
expectoratio
n.

done to aid
in elimination
of secretion
accumulation
9. To maintain
patent
airway
10.To loosen and
mobilize
secretions,
and allow
excretion of
mucus.
11.Achieve
health and
well-being.