NURSING CARE PLAN

Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus production secondary to
Community Acquired Pneumonia as evidenced by a respiratory rate of 39, effective cough, use of
accessory muscles when breathing, oxygen saturation of 93%, and a verbalization of “Marigatan nak
mangiruar toy plemak, Maam.”

Nursing Inference: Community Acquired Pneumonia is an inflammation of the lung parenchyma

associated with alveolar edema and congestion. In response to the inflammation, excess mucus is
produced which can block the small airways and reduce respiratory efficiency. Over-production of
mucus leads to frequent coughing, which further irritates the tissues and causes even more mucus
production. Hence, ineffective airway clearance.

Nursing Goals: After 12 hours of rendering effective nursing care, the patient will be able to maintain
a patent airway as evidenced by a respiratory rate between 12-20 cycles per minute, absence of
ineffective cough, does not use the accessory muscles when breathing, oxygen saturation of 98-
100% and a verbalization of, “Mairuruwar ko dagitoy plema kon, Maam.”

Nursing Interventions and Rationale:

Nursing Interventions Rationale

1. Administer medications such as
antibiotics and bronchodilators, as
ordered.
2. Elevate the head of the bed and change
position frequently.
3. Teach and assist the patient with
proper deep-breathing exercises.
4. Teach and assist the patient in proper
splinting of the chest and effective
coughing while in an upright position.
5. Assist the patient in nebulization
therapy and chest physiotherapy.
6. Provide supplemental oxygen therapy,
as ordered.
7. Provide health education about the
importance of increasing fluid intake
that is warm.
8. Encourage the patient to ambulate as
tolerated.
To alleviate the cough and stops the growth of
bacteria.
To promote chest expansion, aeration of lung
segments, mobilization, and expectoration of
secretions.
To facilitate the maximum expansion of the
lungs and smaller airways and improve the
productivity of cough.
To help the patient remove most secretions;
reduce chest discomfort.
To humidify the airway to thin secretions and
facilitate liquefaction and expectoration of
secretions; to loosen and mobilize secretions in
smaller airways that cannot be removed by
coughing.
To prevent hypoxemia.
To aid in the mobilization and expectoration of
secretions.
To mobilize secretions and reduce atelectasis.

Nursing Evaluation: After 12 hours of rendering effective nursing care, the patient was able to
maintain a patent airway as evidenced by a respiratory rate between 18 cycles per minute, absence
of ineffective cough, does not use the accessory muscles when breathing, oxygen saturation of 98%
and a verbalization of, “Mairuruwar ko dagitoy plema kon, Maam.”