I.
CARE PLAN
ASSESSMENT EXPLANATION OF
THE PROBLEM
S The nursing
>productive cough diagnosis of Ineffective
*few hours PTA Airway Clearance is
>persistence of above defined as the inability to
symptoms clear secretions or
>DOB and pale skin (pallor) obstructions from the
respiratory tract to
O maintain a clear airway.
Vital Signs (NANDA, 2019)
>SPO2 = 87%
>RR=48cpm Upon ausculatation
crackles are heard on the
>deep breaths right lower lobes of the
>auscultation of lung sounds lungs due to retained
(crackles) secretions of the patient.
Secretions is still eminent
Nursing Diagnosis: that the patient has not
Ineffective Airway Clearance expoctorated all secretions
related to retained secretions brought about by
pneumonia.
Mechanisms that exist in
the lower bronchioles and
alveoli to maintain the
patency of the airway
include the mucociliary
system ,macrophages, and
the lymphatics. When
mucociliary is impaired
due to mucus plug this
OBJECTIVES
Goal: Patient will
maintain clear, open
airways as evidenced by
normal breath sounds,
normal rate and depth of
respirations, and ability to
effectively cough up
secretions after treatments
and deep breaths.
STO
- Within 10 minutes of
health teachings, the
patient’s
parents/family will
Note for changes in
identify and avoid
hear rate and
specific factors that
temperature.
inhibit effective airway
clearance.
- recognize the
significance of changes in
sputum to include color,
character, amount, and
odor.
LTO
- Within 3 days of
nursing interventions, the
patient will manifest
clear, open airways as
1
INTERVENTIONS RATIONALE
Dx:
Assess respiration.
A change in the usual
Note quality, rate,
respiration may mean
pattern, depth, flaring
respiratory compromise.
of nostrils, dyspnea
An increase in respiratory
on exertion, evidence
rate and rhythm may be a
of splinting, use of
compensatory response to
accessory muscles,
airway obstruction.
and position for
breathing.
Increased work of
breathing can lead to
tachycardia . Retained
secretions may be a sign
of an existing infection or
inflammatory process
manifested by a fever or
increased temperature.
Use pulse oximetry Pulse oximetry is used to
to monitor oxygen detect changes in
saturation oxygenation.
EVALUATION
FULLY met if:
The patient is able to
maintain the airway patency
as evidenced by clear breath
sound, normal respiratory
depth and rate, and noiseless
respiration.
PARTIALLY met if:
The patient is able to
maintain almost the airway
patency as evidenced by few
crackles in breath sound,
normal respiratory depth and
rate, and presence of noise
during respiration.
NOT met if:
The patient is not able to
maintain the airway patency
as evidenced by crackles in
breath sound, irregular
respiratory depth and rate,
and presence of noise during
respiration.
allow invasive bacteria to
adhere and colonize the
airways. This affects the air
sacs or alveoli in
exchanging gases in the
lungs and causes it to have
ineffective airway
clearance.
Community acquired
pneumonia is one of the
most common serious
infections in children
especially in infants.
Streptococcus pneumoniae
and viruses are the most
common causes in infants
three weeks to three
months of age.when
exposes to Due to their
weak immune system
bacteria or viruses can
easily enter the airway.
evidenced by normal
breath sounds, normal
rate and depth of
respirations, and ability to
effectively cough up
secretions after treatments
and deep breaths.
2
Abnormal breath sounds
Auscultate lungs for
can be heard as fluid and
presence of normal
mucus accumulate. This
or adventitious
may indicate ineffective
breath sounds.
airway clearance.
Tx:
Upright position limits
Position the patient
abdominal contents from
with the head
pushing upward and
elevated if tolerated.
inhibiting lung expansion.
Regularly check the
This position promotes
patient’s position to
better lung expansion and
prevent sliding down
improved air exchange.
in bed.
Bronchial tapping helps
mobilize bronchial
Perform bronchial secretion from smaller
tapping airways that cannot be
eliminated by means of
coughing or suctioning.
A variety of medications
Give medications as are prepared to manage
prescribed, such as specific problems. Most
ampicillin , promote clearance of
amikacin,paracetamo airway secretions and
l, salbutamol, and N- may reduce airway
Acetyl Cystein . resistance.
 Ed: Fluids such as breast milk
Advise the mother to helps minimize the mucosal
breastfeed drying and maximize ciliary
continuously. action to move secretion. It
also facilitates easy
elimination of secretion.

Advise the client’s

significant others to
comply with annual
check up required for
the client.

Vinegar is a natural and

Instruct the client’s powerful cleaner that
significant others to deodorizes, kills mildew
clean walls with and do not emit any harsh
vinegar and water fumes. Thus, providing a
natural killer for

Reitterate the
importance of hand Hand hygiene prevents
hygiene before spread of infection
holding the baby.

3
References:
 Tortora, G. & Derrickson, B. (2014). Principles of Anatomy and Physiology.14th Edition. John Wiley and Sons.pdf
 Berman, A. et al. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts Process and Practice. 10th Edition. Pearson Education Incorporation.pdf
 Kokai, D. et al. (2018). N-acetyl-cysteine increases the replication of Chlamydia pneumoniae and prolongs the clearance of the pathogen from mice. Journal of Medical
Microbiology. DOI 10.1099/jmm.0.000716.pdf
 Bell, D. & Jones, J. (n.d.). Reticular and linear pulmonary opacification. Retrieved from. https://radiopaedia.org/articles/reticular-and-linear-pulmonary-opacification?
lang=us
 Bennett, N. J. (2018). Imaging in Pediatric Pneumonia. Retrieved from. https://emedicine.medscape.com/article/1926980-overview
 Drugbank. (2019). Salbutamol. Retrieved from. https://www.drugbank.ca/drugs/DB01001
 Sabtu. (2013). Ineffective airway clearance. Retrieved from http://nursinginterventionsrationales.blogspot.com/2013/07/ineffective-airway-clearance.html