I

Nursing Care Plan

Airway
Innefective Airway Clearance
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Innefective After 8 hours Independent: After 8 hours of
“nahihirapan Airway of nursing Mobilize the client nursing
ako huminga”as clearance intervention as soon as intervention the
verbalized by related to the patient possible. This patient is be
the patient. excessive will be able reduces risk or able to
mucous as to establish effects of establish the a
Objective: evidence by within a atelectasis, normal range of
Diminushed presence of normal range enhancing ling respiratory rate
breath sounds crackles and of respiratory expansion and of 18 bpm and
wheezes rate of 12-20 drainage of after a 8 hours
Alteration in upon bpm and different lung shift there is a
respiratory rate auscultation after a 8hour segments decrease of
with shift there is fatigue and
Difficulty repiratory a decrease Encourage deep- minimize the
verbalizing rate of of fatigue breathing and secretions.
25bpm and minimize coughing Goal met.
Restessness the exercises. To
secretions maximize effort
Presence of
crackles and Increase fluid
wheezes upon intake to at least
auscultation 2,000 ml/day
withing cardiac
tolerance.
Hydration can
help prevent the
accumulation of
viscous
VS: secretions and
BP: 120/80 improve
mmHg secretion
HR: 95 clearance.
PR: 93/min
RR: 25 bpm Position
Temp: 37.1°c appropriately. To
02: 95% prevent
vomiting witha
aspiration into
lungs.

Dependent:
Preform or assist
the client learning
airway clearance
techniques

Administer
oxygen via mask,
as indicated. To
increase oxygen
available for
cardiac
function/tissue
perfusion