Memorial University of Newfoundland School of Nursing- Extended CER / N3512

Nursing Dx

Supportive Data

Intervention/Strate
gies

Rationale

Evaluation

Ineffective airway
clearance

Goal(s)/Expected
Outcome(s)
Patient will
demonstrate clear
breath sounds and
unlaboured
breathing by the end
of the clinical week.
O2 sats will be
maintained above
92% without
supplemental oxygen
by the end of the
clinical week.

Subjective:
Patient states that
her coughs are
yucky
Patient states she
is short of breath
Objective:
Patient has a wet,
productive cough
Patients oxygen
sats are between
89-94
Chest xray
revealed fluid on
the lungs
Patients WBC
count is elevated
Patients breathing
is shallow and
laboured, as
evident by
respiratory
assessment
Patient using
accessory
muscles to
breathe deeply
Dyspnea
Increased
respiratory rate
(>30)

Auscultate breath
sounds before and
after each Ventolin
treatment (Q3H).

Monitor respiratory
pattern, including:
rate, depth, and
patients effort.

Monitor pulse
oxygen saturation at
regular intervals
(Q1H).

Administer oxygen
and ventolin as
ordered.

Breath sounds are

normally clear. The
presence of crackles
during breathing
indicates fluid in the
airway, and
wheezing can
indicate obstruction.
M. Doenges, MF
Moorhouse, & A.
Murr. Nurses
Pocket Guide.
(2006).
Normal respiratory
rate for a pediatric
patient is 20-25.
When secretions are
present and
breathing is
laboured,
respiratory rate will
increase.
Oxygen saturation
less than 90%
indicates
oxygenation
problems.
Clark, AP, Giuliano
K., Chen HM: Pulse
oximetry revised.
Clin Nurse Spec

Goals not met.

Patient has equal,
bilateral breath
sounds which are
clear and
unlaboured in the
upper lung lobes.
Patient does not
have air movement
in the lower lobes.
Infection/inflammati
on does not seem to
be clearing with
regular
corticosteroids, and
antibiotic treatment.
Repeat chest xray
has been ordered.
O2 sats are not
being maintained
above 92%.
Patient still requires
blowby oxygen
supplementation.

Patient is
breathing
shallow
Patient has nasal
flaring

20(6), 268-272,
2006.

Monitor for side

effects of
bronchodilator and
steroid,

Oxygen can increase

the patients O2 sats
and ventolin will
open up airways and
reduce
inflammation.
P. Swearingen.
Manual of medical
surgical nursing
care. (2008).
Bronchodilators and
steroids can cause
tachycardia, anxiety,
tremors, insomnia.
A. Perry & P. Potter.
Clinical Nursing
Skills & Techniques.
(2010).