No

Nursing Diagnosis
Ineffective airway clearance
related to accumulation of
secret production,
characterized by :
Subjective data :
Patient said that she have
cough and hoarse voice.
Objective data :
Abnormal breath sounds
(rhonchi), cough, sputum (+),

Outcome
After 3 x 24
hours of care,
patient's
secretions are
mobilized and
airway is
maintained free
of secretions, as
evidenced by :
Clear lung
sounds,
Able to
effectively
cough up
secretions
after
treatments
and deep
breaths.
Respiratory
rate at about
12-20
times/minute
Moves
sputum out
of airway

Intervention
Assist patient in
performing coughing
and breathing
maneuvers.

Encourage oral intake

of fluids (warm) at
least 2000 mL/day
within level of cardiac
tolerance.

Rationale
To improve
productivity of
the cough. D
eep breathing
promotes
oxygenation
before controlled
coughing

To prevent
drying of
secretions and
to help liquefy
secretions

To reduce broncs
Collaborate to
spasm and
administer medications increase secret
(e.g., mucolytic
mobilization
agents,bronchodilators,
expectorants

Evaluation
After 3 x 24 hours of given treatment, client will :

Maintain airway patency.

Expectorate/clear secretions readily.
Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless,
improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
Verbalize understanding of cause(s) and therapeutic management regimen.
Demonstrate behaviors to improve or maintain clear airway.
Identify potential complications and how to initiate appropriate preventive or corrective
actions.,

http://wps.prenhall.com/wps/media/objects/3918/4012970/NursingTools/ch50_NCP_IneffAirClear_1
395-1396.pdf

Abnormal data
Ineffective airway clearance
related to accumulation of
secret production, characterized
by :

Etiology
Problem
Infection of epitelial cells of
Ineffective airway clearance
nasal passage airway
receptor irritation cholinergic
stimulation broncho

constriction cough
Subjective data :
Patient said that she have cough
and hoarse voice.
Objective data :
Abnormal breath sounds
(rhonchi), cough, sputum (+),

airway receptor irritation

secret production increase
accumulation of secret