NCP PROPER

CUES EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALES EVALUATION

PROBLEM
SUBJECTIVE: Ineffecive Airway Clearance STO: DIAGNOSTICS:
Ang problema ko is the inability to clear secretions After 4 hours of nursing
or obstruction of the respiratory intervention, the client will
lang eh nahihirapan >Assess airway for >Maintaining patent
tract to maintain airway hygiene. be able to maintain patent
akong huminga at patency. airway is always the first
airways as evidence by:
madali akong This was the problem of the priority, especially in
- no wheezing
hingaling kapag patient since he has asthma and
has a non- productive cough. -no crackles cases like trauma, acute
gumagalaw ko - no use os
This conditions may cause the neurological
patient to have obstructed sternocleidomastoid muscle
Hindi ko mailbas airways due to accumulation of
decompensation, or
tong phlegm ko secretions and bronchospasm LTO: cardiac arrest.
due to asthma. After 1 day
of nursingintervention, theclient
Ineffective airway clearance can > Auscultate lungs for Abnormal breath sounds
OBJECTIVES: will beable
be a serious problem if left presence of normal or can be heard as fluid and
- slightly uses toexpectorateretainedsecretion
untreated because
sternocleidomastoid
s andmaintain normal breathing adventitious breath mucus accumulate. This
pattern.
muscle Maintaining a patent airway sounds, as in the may indicate airway is
- crackles noted has always been vital to life. following: obstructed.
upon auscultation in When problem concerning
the lung fields
the airway happens, Decreased or These may indicate
- non productive
coughing takes place, which absent breath presence of a mucous
cough noted
- wheezes on both is the main mechanism for sounds plug or other major
lung field clearing it. However, obstruction.
- RR of 18 cpm coughing may not always be Wheezing
- SPO2 of 98%
easy to everyone especially This may indicate partial

to those patients with airway obstruction or

incisions, trauma, resistance. This

respiratory muscle fatigue, may indicate presence of
or neuromuscular Coarse secretions along larger
weakness. Mechanisms that crackles airways.
exist in the lower
bronchioles and alveoli to This may indicate
maintain the patency of the > Assess respirations. presence of secretions
airway include the Note quality, rate, pattern, along larger airways.
mucociliary system, depth, flaring of nostrils,

macrophages, and the dyspnea on exertion, A change in the usual

lymphatics. evidence of splinting, use respiration may mean
of accessory muscles, respiratory compromise.
and position for breathing An increase in
Reference: respiratory rate and
> Note for changes in rhythm may be a
Http://www.rncentral.com, R. |. mental status. compensatory response
(n.d.). Ineffective Airway
Clearance | RNCentral.com. to airway obstruction.
Retrieved October 17, 2016, from
http://www.rncentral.com/nursing-
library/careplans/iac/
> Increasing lethargy,
confusion, restlessness,
and/or irritability can be
initial signs of cerebral
>Note for changes in HR, hypoxia. Lethargy and
BP, and temperature. somnolence are late
signs.

> Increased work of

 breathing can lead to
tachycardia
and hypertension.
Retained secretions or
atelectasis may be a sign
of an existing infection or
> Note cough for efficacy inflammatory process
and productivity. manifested by a fever or
increased temperature.

> Coughing is a
mechanism for clearing
secretions. An ineffective
cough compromises
airway clearance and
prevents mucus from
being expelled.
Respiratory muscle
fatigue, severe
bronchospasm, or thick
> Use pulse oximetry to and tenacious secretions
monitor oxygen are possible causes of
saturation; assess arterial ineffective cough.
blood gases (ABGs)
>Pulse oximetry is used
to detect changes in
 oxygenation. Oxygen
saturation should be
maintained at 90% or
greater. Alteration in
ABGS may result in
> Assess hydration increased pulmonary
status: skin turgor, secretions and
mucous membranes, respiratory fatigue.
tongue.
>Airway clearance is
impaired with poor
Assess for abdominal or hydration and
thoracic pain. subsequent secretion
thickening.

>Pain can result in

THERAPEUTIC: shallow breathing and an
ineffective cough.
> Position the patient
upright if tolerated.
Regularly check the
patients position to
prevent sliding down in >Upright position limits
bed. abdominal contents from
pushing upward and
inhibiting lung expansion.
> Coordinate with a This position promotes
respiratory therapist for better lung expansion
chest physiotherapy and and improved air
nebulizer management as exchange.
indicated.
> Chest physiotherapy
includes the techniques
of postural drainage and
chest percussion to
mobilize secretions from
> Provide oral care TID smaller airways that
cannot be eliminated by
means of coughing or
suctioning.

> Pace activities > Oral care freshens the

especially for patients mouth after respiratory
with reduced energy. secretions have been
Maintain planned rest expectorated.
periods. Promote energy-
conservation methods. > Fatigue is a
contributing factor to
ineffective coughing.

>Assist patient when Effective coughing

moving. requires enough energy

and may consume an
 extra effort to the patient.

> To prevent patient from

> Consider verbalization being injured and avoid
of feelings. fatigue which increases
the O2 demand of the
body.

>Recognize reality of
situation. Anxiety adds to
oxygen demand, and
hypoxemia potentiates
EDUCATIVE: respiratory distress or
>Teach the patient the cardiac symptoms, which
proper ways of coughing in turn increases anxiety.
and breathing. (e.g., take
a deep breath, hold for 2
seconds, and cough two
or three times in >The most convenient
succession). way to remove most
secretions is coughing.
So it is necessary to
assist the patient during
this activity. Deep
>Educate the patient in breathing, on the other
the following: hand, promotes
 Optimal oxygenation before
positioning controlled coughing.
(sitting position)
Use of pillow or >The proper sitting
hand splints position and splinting of
when coughing the abdomen promote
Use of effective coughing by
abdominal increasing abdominal
muscles for
pressure and upward
more forceful
diaphragmatic
cough
movement. Controlled
Use of quad
coughing methods help
and huff
mobilize secretions from
techniques
smaller airways to larger
Use of
airways because the
incentive
spirometry coughing is done at

Importance of varying times.

ambulation and Ambulation promotes
frequent lung expansion,
position mobilizes secretions, and
changes lessens atelectasis.

> Instruct patient about

the need for adequate
fluid intake even after
 hospital discharge.

>Explain further the

effects of smoking,
including secondhand
smoke.

>Hydration facilitates
easy elimination of
secretions.

>Chemical irritants and

allergens can increase
mucus production and
bronchospasm.

References:

Ineffective Airway Clearance. (n.d.). Retrieved October 17, 2016, from http://ncp-blog.blogspot.com/2011/01/ineffective-airway-clearance.html

Ineffective Airway Clearance of COPD. (n.d.). Retrieved October 17, 2016, from http://nanda-nursinginterventions.blogspot.com/2012/05/ineffective-airway-clearance-
of-copd.html