NURSING CARE PLAN

Ineffective airway clearance

CUES NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

After 8 hrs of nursing Independent: After 8 hours of nursing

Subjective: High risk for ineffective intervention the patient -Provide the client -Promotes Relaxation intervention the patient
airway clearance related will be able to: comfort measures: and may help improve was able to;
to increased secretions -Sustain respiratory rate *Quiet Environment sleeping pattern. --Sustain respiratory rate
secondary to within normal range: RR- *Clean Environment within normal range: RR-
tracheostomy, 12-20cpm. *Proper Ventilation 12-20cpm.
Objective: obstruction of inner -Allay restless-ness. *Regulate Environment - Allay restless-ness
-DOB cannula, or displacement Temperature
-Wheezes on both lungs or tracheostomy tube. -Position the client in -To promote lung
-(+) Restlessness side-lying position with expansion and to
-On tracheostomy tube head of the bed prevent aspiration.
attached elevated.
-(+) coughing of blood -Change position every 2 -To take advantage of
With vital signs of: hours and prn. gravity decreasing
PR: 101bpm pressure on the
RR: 18cpm diaphragm and
TEMP: 35.3 enhancing
BP: 120/80 drainage/ventilation to
02: 99% different lung segment.

-Observe for S/Sx of -To identify infectious

Infection process/promote timely
intervention.

-Suctioned patient -Duration should be

limited to 5-sec limited to reduce hazard
duration. of hypoxia.

Dependent:
Administer due
medications as ordered
by the physician.

Collaborative:
Assist the client when
specific laboratory
procedures are needed