Nursing Care Plan

Return to Care Plan Listing
 






Medical Diagnoses: Ineffective Airway Clearance, Inflammation, COPD, Presence of Secretions

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

     

Pt stated “I feel like I can’t breathe”

     

Pt stated “I can’t clear my throat. If I can cough, it usually doesn’t help.”

     

     

Objective:

Pt demonstrates ineffective coughing.

     

Pt struggles for air.

     

Pt experiences a very flushed face after any activity including, turning, bathing, and cleaning up.

     

Pt demonstrates a respiratory rate of 36 breaths per minute.

     

Pt’s respirations are very labored and non-even.

Problem:

Ineffective Airway Clearance

    

Long Term:

Pt will be able to verbalize the understanding of appropriate measures to maintain a patent airway at all times by discharge.

     

*Discuss and teach the pt the importance of performing coughing and deep breathing exercises.

     

Rationale:

“This technique can help increase sputum clearance and decrease cough spasms. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.” (Ackley & Ladwig, 2008, p.125-126)

     

“Many patients with COPD have developed ineffective coughing patterns that do not adequately clear their airways of sputum. The main goals of effective coughing are to conserve energy, reduce fatigue, and facilitate removal of secretions. (Lewis, 2007, p. 646)

     

     

    

I

Unable to evaluate pt goal due to confusion. Hypothetically, once the pt was oriented again, I would have her verbalize her understanding of measures to take on her own to maintain a patent airway.


Unable to evaluate interventions to due to confusion. Although, the pt was able to perform the coughing and deep breathing after demonstration by the staff, it is unlikely that she would be able to do this on her own at this time. Right now, the pt would need continuous reinforcement about how to perform the exercises with assistance from the staff.

R/T:

Inflammation

     

Presence of secretions

 

COPD


Short Term:

Pt will demonstrate effective coughing and deep breathing exercises within three days, by [Month] 6, [Year].

*Reposition the pt at least once every two hours to optimize respirations. Position the pt with the HOB upright at least 45 degrees at all times.

     

Rationale:

“An upright position allows for maximal lung expansion.” (Ackley & Ladwig, 2008, p. 125)

     

*Encourage coughing and deep breathing exercises.

     

Rationale:

***Same citations as long term goal!

     

 (Ackley & Ladwig, 2008, p.125-126)

     

 (Lewis, 2007, p. 646)

     


I

     

Goal met. The pt demonstrated effective coughing and deep breathing upon observation. After performing deep breathing exercises, the pt’s O2 saturation increased from 93% to 95%.

Continue interventions as listed. Reposition the pt at least once every two hours with the HOB upright at least 45 degrees. Continue to encourage coughing and deep breathing exercises to promote airway clearance and appropriate O2 saturation.

AEB:

Patient struggling to cough

     

Pt’s face becomes very flushed after any activity.

     

Pt appearing to struggle for air.

    

Pt states she feels like she can’t clear her throat and feels like she’s having trouble breathing.

     

Pt’s respirations are at 36 breaths per minute and are very labored and non- even.

    

 

1,800 Cardiovascular review flash cards, download now and ace your exams

   

    

*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.                                                                                                                              

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’ Brien, P.G., Bucher, L. (2007). Medical- surgical nursing: Assessment and management of clinical problems (7th ed.). St. Louis : Mosby Elsevier.


Return to Table of Contents