Busca, Reymark A. NURSING CARE PLAN

 

  Busca, Reymark A. BSN IV C

         Ineffective Airway Clearance

   Breathing comes naturally and effortlessly to everyone. But there are some who are incapable of keeping their airways clear and their lungs healthy. Maintaining a patent airway has always been vital to life. When a problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it.

    The best nursing care plan should be prioritized in order to aid the condition for the clients experiencing cough.

Nursing Assessment:

Objective Data: dyspnea and difficulty of breathing

Subjective Data: “maglisod kog tulog jud magabie kay agis akong ubo nga gahi kaayo agi sa plema”, as verbalized by my sister

Nursing Diagnosis:

Ineffective airway clearance related to increased mucus production as evidenced by coughing with yellowish phlegm

Nursing Care Plan and Goals:

General Objectives: to facilitate the maintenance of the supply of oxygen to all body cells.

Specific Objectives: After 1 hour of  nursing intervention my client (my sister) will be able to expectorate phlegm.

Nursing Interventions:

Independent Interventions:

1.      Promote systemic fluid hydration, as appropriate. This helps to liquefy secretions and facilitates expectoration of mucus.

2.      Avoid milk and milk products. Milk products tends to thicken secretions.

3.      Instruct her to avoid exposing to irritants like cigarette smoke, aerosols, dust and extremes of temperature. Bronchial irritants causes bronchoconstriction and increased mucus production which interfere with the airway clearance.

4.      Promote bed rest. This prevents exhaustion and oxygen consumption.

Dependent Interventions:

1.      Take medications (Salbutamol) as prescribed. Bronchodilator reduces bronchospasm; it opened congested airways and facilitating ventilation

Nursing Evaluation:

    Goals partially met as evidenced by the client cough continue to be productive with moderate thick, yellowish sputum.