Prioritized Nursing Care Plan Nursing Diagnosis: Ineffective Airway Clearance r/t pneumonia and COPD aeb adventitious

breath sounds & inability to clear secretions Goal: Patient will maintain a patent airway while in my care. Outcomes: Patient will maintain an Oxygen saturation > 90% while in my care. (Normal range 95-100%, but patient has COPD) Patient will not smoke cigarettes while in my care, and continues his smoking cessation plan while in my care. Patient will maintain adequate hydration during my care to assist with thinning secretions. Nursing Actions (1) Monitor Respiratory Patterns q4h or PRN (2) Assess Breath Sounds q4h Scientific Rationale Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12-20. With secretions in the airway, the respiratory rate will increase. (Ackley, 129) Ausculate breath sounds q4h. Breath sounds are normally clear or scattered fine crackles at base, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid at the airway. Wheezing indicates an airway obstruction. (Ackley, 129) Monitor blood gas values and pulse oxygen saturation levels as available. A partial pressure of oxygen less than 80 indicates significant oxygenation problems. Normal values are 80-100. Oxygen saturation less than 90% also indicates significant oxygenation problems (normal value 95-100%) (Ackley, 129) Encourage movement at least q2h. Body movement helps to mobilize secretions. Supine position should be avoided. Encourage all ROM. (Ackley, 130) Teach patient what smoking can do to the body. Explain different methods of quitting available, and make sure that patient understands options. Help patient come up with a plan that will work for him.

(3) Monitor Blood Gas Values as available.

(4) Encourage Activity as tolerated q2h & q shift. (5) Teach the importance of not smoking