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



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