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Nursing Diagnosis Ineffective Airway Clearance

Ineffective Airway Clearance
  • ( )Actual
  • ( )Potential

Related To :
  • Atrificial airway
  • Excessive or thick secretions
  • Inability to cough effectively
  • Infection
  • Obstruction/restriction
  • Pain
  • Other

As evidenced by :
Major:
  • Ineffective cough.
  • Inability to remove airway secretions.
Minor:

  • Abnormal breath sounds.
  • Abnormal respiratory rate, rythm, depth.

Plan and Outcome

The patient will:
  • Maintain patent airway A.E.B.:
    • Clear breath sounds or breath sounds consistent with own baseline.
    • Respirations easy and un-labored.
    • Normal resp. rate.
  • Other:

Nursing Interventions
  • Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.
  • Position: HOB elevated ___ degrees.
  • Promote optimum level of activity for best possible lung expansion :
    • Ambulate q ___ for ___ min.
    • Chair q ___ for ___ min.
    • Turn/reposition q ___.
  • Suction q ___ hours (and prn) per:
    • Nasal
    • Oral
    • Tracheal
  • Encourage fluids when indicated.
  • Other:________________



Patient/Significant other signature



__________________________
RN signature

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