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NURSING CARE PLAN: Ineffective Breathing Pattern Related to Excessive Mucus and Retained Secretions

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Ineffective Inspiration After 8 hours of Assess rate and depth When pneumonia is severe, After 8 hours of
No verbal cues Breathing and/or expiration nursing of respirations and chest the client may require nursing intervention
Pattern related that does not intervention the movement. Monitor for endotracheal intubation and the client is able to:
Objective data:
excessive provide client will be signs of respiratory mechanical ventilation to keep
(+) Tachypnea Exhibit breathing
(+) Wheezes mucus and adequate able to: failure, for example, airways clear.
retained ventilation cyanosis and severe without difficulty
(+) Abnormal
breathing secretions Exhibit breathing tachypnea.
without difficulty have patent airway
pattern ; RR=25
Auscultate lung fields, Decreased airflow occurs in
Will have patent areas consolidated with fluid. have clear
Vital signs as noting areas of
follows: airway Bronchial breath sounds breathing sounds
decreased or absent
T: 36.5 C airflow and adventitious (normal over bronchus) can
BP 147/85 Will have clear RR=19 (within
breath sounds, such as also occur in consolidated
RR:25 breathing normal respiratory
crackles and wheezes. areas. Crackles, rhonchi, and
HR: 87 sounds rate)
wheezes are heard on
Patient is under inspiration and expiration in
Will have
tracheostomy to response to fluid accumulation,
Normal
mechanical thick secretions, and airway
ventilator respiratory rate
spasm or obstruction.

Keeping the head elevated


Elevate head of bed;
lowers diaphragm, promoting
change position
chest expansion, aeration of
frequently.
lung segments, and
mobilization and expectoration
of secretions to keep the
airway clear.

Suction, as indicated, for Stimulates cough or


example, oxygen mechanically clears airway in
desaturation related to client who is unable to do so
because of ineffective cough
airway secretions. or decreased level of
consciousness.

Collaborative:
Facilitates liquefaction and
Assist with and monitor removal of secretions. Postural
effects of nebulizer drainage may not be effective
treatments and other in interstitial pneumonias or
respiratory those causing alveolar
physiotherapy, exudates or destruction.
percussion, and postural Coordination of treatments,
drainage. Perform schedules, and oral intake
treatments between reduces likelihood of vomiting
meals and limit fluids with coughing and
when appropriate. expectorations.

Aids in reduction of
bronchospasm and
Administer medications,
mobilization of secretions.
as indicated.
Fluids are required to replace
Provide supplemental
losses, including insensible
fluids such as IV,
losses, and aid in mobilization
humidified oxygen, and
of secretions. Note: Some
room humidification.
studies indicate that room
humidification has been found
to provide minimal benefit and
is thought to increase the risk
of transmitting infection.

Follows progress and effects


Monitor ABGs, and of disease process and
pulse oximetry readings. therapeutic regimen and
facilitates necessary
alterations in therapy.