Objective of

Date/Time Cues Need Nursing Diagnosis Nursing Intervention Evaluation

Care
N Subjective: A Ineffective airway After 2 days of 1. Assess airway for NOVEMBER 27, 2018
O C clearance related to nursing patency. @ 3:00 p.m.
V T copious and interventions, the
E I tenacious patient will R: Maintaining patent “GOAL PARTIALLY
M V tracheobronchial maintain clear, MET”
airway is always the first
B I secretions as open airways as
E T evidenced by evidence by: priority, especially in After 2 days of nursing
R Y abnormal breath cases like trauma, acute interventions, the
- sounds and A.) Normal breath neurological patient will maintain
26, E respiratory rate sounds decompensation, or clear, open airways as
X secondary to cardiac arrest. evidenced by:
2 E pulmonary disease: B.) Respirations
0 R Bilateral pneumonia easy and non- 2. Auscultate lungs for a.) Clear sounds hear
1 Objective: C labored. on both lung fields
presence of normal
8 I Rationale:
VS: S The inflammatory C.) Vital signs or adventitious b.) Use of accessory
@ E response to infection within normal breath sounds, as in muscles during
-BP: 140/100 causes tissue edema range the following: breathing
7:30 a.m. -CR: 119 P and exudates
RR: 32 A formation in the R: Abnormal breath c.) Maintained vital
Temp: 35.7 T lungs, the sounds can be heard as signs of:
T inflammatory
fluid and mucus
-Crackles E response can narrow -BP: 90/70
R and potentially accumulate. This may (Normal Range:
heard on both
lung fields N obstruct bronchial indicate airway is 110/70 - 130/90)
passages and alveoli. obstructed.
-Ineffective or -CR: 111 (Normal
absent cough Reference: 3. Assess respirations. Range: 60-100 bpm)
Gulanick, M., & Note quality, rate,
-Use of Myers, J.L. (2014). pattern, depth, -RR: 28
accessory Nursing care plans: (Normal Range: 16-20
flaring of nostrils,
muscle Diagnosis and cpm)
during interventions. (6th dyspnea on exertion,
respirations ed.) evidence of splinting, - Temp: 35.9 (Normal
use of accessory Range: 36.5 - 37.5)
- muscles, and
Restlessness position for Posadas,T.M., Stn
breathing.
-Combative
state
R: A change in the
-Chest PA: usual respiration may
Bilateral mean respiratory
pneumonia compromise. An
increase in respiratory
rate and rhythm may be
a compensatory
response to airway
obstruction.

4. Note for changes in

mental status.

R: Increasing lethargy,
confusion, restlessness,
and/or irritability can be
initial signs of cerebral
hypoxia. Lethargy and
somnolence are late
signs.

5. Note for changes in

HR, BP, and
temperature.

R: Increased work of
breathing can lead to
tachycardia and
hypertension. Retained
secretions or atelectasis
may be a sign of an
existing infection or
inflammatory process
manifested by a fever or
increased temperature.

6. Assess for
abdominal or
thoracic pain.

R: Pain can result in

shallow breathing and
an ineffective cough.

7. Position the patient

upright if tolerated.
Regularly check the
patient’s position to
prevent sliding down
in bed.

R: Upright position limits

abdominal contents
from pushing upward
and inhibiting lung
expansion. This position
promotes better lung
expansion and
improved air exchange.

8. Perform
nasotracheal
suctioning as
necessary,
especially if cough is
ineffective.
R: Suctioning is needed
when patients are
unable to cough out
secretions properly due
to weakness, thick
mucus plugs, or
excessive or tenacious
mucus production.

9. Give medications as
prescribed, such as
antibiotics, mucolytic
agents,
bronchodilators,
expectorants, noting
effectiveness and
side effects.

R: A variety of
medications are
prepared to manage
specific problems. Most
promote clearance of
airway secretions and
may reduce airway
resistance.

10. Provide postural

drainage,
percussion, and
vibration as ordered.

R: Chest physical
therapy helps mobilize
bronchial secretions; it
should be used only
when prescribed
because it can cause
harm if patient has
underlying conditions
such as cardiac disease
or increased intracranial
pressure.

11. Provide oral care

every 4 hours.

R: Oral care freshens

the mouth after
respiratory secretions
have been
expectorated.

12. If secretions cannot

be cleared, consider
the need for an
intubation.

R: Readiness for an
emergency helps
prevent further
complications.
Intubation may be
needed to facilitate
removal of tenacious
and copious amounts of
secretions and provide
source for augmenting
 oxygenation.

Reference:

NANDA-I. (2011). Nursing

diagnoses:Definitions and
classification 2012-14 (9th
ed.). New York, NY:Wiley-
Blackwell.

Carpenito-Moyet,L. (2012).
Nursing diagnosis:
Application to clinical
practice (14th ed.).
Philadelphia, PA:
Lippincott, Williams, &
Williams.