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Pneumonia-Ineffective Airway Clearance

The patient presents with bronchopneumonia and ineffective airway clearance due to retained secretions. The nursing diagnosis is ineffective airway clearance related to retained secretions as evidenced by signs of respiratory distress. The plan is to monitor vital signs, auscultate breath sounds, elevate the head of bed, and encourage increased fluid intake. Interventions include administering bronchodilators as needed and encouraging rest to improve airway patency and resolve the underlying conditions.

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18K views2 pages

Pneumonia-Ineffective Airway Clearance

The patient presents with bronchopneumonia and ineffective airway clearance due to retained secretions. The nursing diagnosis is ineffective airway clearance related to retained secretions as evidenced by signs of respiratory distress. The plan is to monitor vital signs, auscultate breath sounds, elevate the head of bed, and encourage increased fluid intake. Interventions include administering bronchodilators as needed and encouraging rest to improve airway patency and resolve the underlying conditions.

Uploaded by

NursesLabs.com
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Medical Diagnosis: Bronchopneumonia

Problem: Ineffective Airway Clearance RT Retained Secretions

Assessment Nursing Scientific Planning Interventions Rationale Evaluation


Diagnosis Explanation

Subjective: Ineffective The Choose: 1. Monitor V/S 1. -To


(none) Airway inflammation especially evaluate
Clearance RT and increased respiratory degree of The patient will
rate compromi demonstrate
Retained secretions make The patient will se behaviors to
Objective: Secretions AEB it difficult to demonstrate 2. Auscultate
Ineffective maintain a improve airway
behaviors to breath 2. -To
• Appears weak Cough patent airway, patency.
improve airway sounds, ascertain
& restless which is cause note areas status and
patency. The patient will
• Appears by decrease of note
tachypneic ability to expel decreased/a progress maintain or
• With changes The patient will dventitious or establish
the excessive maintain or
in rate, breath complicati effective airway
rhythm and mucus produced establish sounds as ons
that will lead to clearance AEB
depth of effective airway well as
breathing extensive effective
clearance AEB fremitus
• With DOB and obstruction of respirations and
effective absence of signs
(+) wheezes the airway.
on the right respirations and 3. To of respiratory
lung absence of signs 3. -Elevate maximize distress
• Appears of respiratory HOB or respiratory
cyanotic distress change effort and
The patient will
• With (+) position mobilize
nonproductiv every 2 secrection verbalize
The patient will understanding of
e cough hours as s
• Appears verbalize necessary causative factors
tachycardiac understanding of 4. To prevent and prevent
• Wide-eyed causative factors 4. Keep allergic recurrence of
and prevent environmen reactions problem.
recurrence of t allergen-
problem. free
5. To help

This NCP was made with love by NursesLabs.com


(ignore the Monkey)
liquefy (Change to “will”
secretions to “shall” and
shift to past
5. -Encourage
tense)
client to
increase OFI
to at least
2000 ml/day 6. To
within level promote
of cardiac wellness
tolerance.

6. Encourage
adequate
rest and
limit 7. To treat
activities to underlying
within client conditions
tolerance. and
mobilize
secretions
7. Administer
medications 8. To
such as promote
bronchodilat wellness
ors/
expectorant
s as
indicated

8. Encourage
adequate
bed rest

This NCP was made with love by NursesLabs.com


(ignore the Monkey)

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