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    Ineffective Airway Clearance

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    ChristineAla
    1. The patient has ineffective airway clearance due to excessive mucus secretions as evidenced by desaturation, increased respiration rate, crackles in both lung fields, and labored breathing. 2. The goal is for the patient to have a patent airway and expectorate retained yellowish secretions within 3-4 hours through nursing interventions like positioning, suctioning, and monitoring respiratory status and secretions. 3. Positioning helps maximize lung expansion, suctioning maintains adequate airway patency, and monitoring evaluates ventilation and indicates response to treatment.

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    Ineffective Airway Clearance

    Uploaded by

    ChristineAla
    486 views1 page
    1. The patient has ineffective airway clearance due to excessive mucus secretions as evidenced by desaturation, increased respiration rate, crackles in both lung fields, and labored breathing. 2. The goal is for the patient to have a patent airway and expectorate retained yellowish secretions within 3-4 hours through nursing interventions like positioning, suctioning, and monitoring respiratory status and secretions. 3. Positioning helps maximize lung expansion, suctioning maintains adequate airway patency, and monitoring evaluates ventilation and indicates response to treatment.

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    NCP

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    1. The patient has ineffective airway clearance due to excessive mucus secretions as evidenced by desaturation, increased respiration rate, crackles in both lung fields, and labored breathing. 2. The goal is for the patient to have a patent airway and expectorate retained yellowish secretions within 3-4 hours through nursing interventions like positioning, suctioning, and monitoring respiratory status and secretions. 3. Positioning helps maximize lung expansion, suctioning maintains adequate airway patency, and monitoring evaluates ventilation and indicates response to treatment.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    486 views1 page

    Ineffective Airway Clearance

    Uploaded by

    ChristineAla
    1. The patient has ineffective airway clearance due to excessive mucus secretions as evidenced by desaturation, increased respiration rate, crackles in both lung fields, and labored breathing. 2. The goal is for the patient to have a patent airway and expectorate retained yellowish secretions within 3-4 hours through nursing interventions like positioning, suctioning, and monitoring respiratory status and secretions. 3. Positioning helps maximize lung expansion, suctioning maintains adequate airway patency, and monitoring evaluates ventilation and indicates response to treatment.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Alyssa Loise B.

    Acosta EAMC 3rd Shift

    IV-NUR-1 RLE 1 Maam Terre

    NCP for Ineffective Airway Clearance

    Assessment Nursing Scientific Rationale Objectives/Goals Nursing Rationale Evaluation


    Diagnosis Interventions
    Objective: Ineffective Airway Normally the lungs are Within 3-4 hours of 1. Assessed 1. Provides a basis
    - On endotracheal Clearance related free from secretions. nursing interventions, respiratory rate for evaluating
    tube attached to to excessive Pneumonia bacteria the patient will be able and chest adequacy of
    a mechanical mucus secretions are invading the lung to: movement ventilation and
    ventilator with as manifested by parenchyma thus, Have patent airway indicate response
    the following desaturation and producing Expectorate retained to ineffective
    settings: FiO2 = increase in inflammatory process. yellowish ventilation
    100%, VT = respiration And these responses secretions 2. Maintained on
    320, AC mode, leading to filling of semi-fowlers 2. Positioning helps
    BUR = 16/28, the alveolar sacs with position maximize lung
    3. Suctioned
    PEEP = 10 exudates leading to expansion
    - (+) crackles on patient limited to 3. To maintain
    consolidation.
    both lung fields 5-sec duration adequate airway
    - Labored 4. Monitor changes
    Source: patency
    breathing in SpO2.
    https://www.scribd.co
    - RR = 31 bpm Auscultate 4. To know the
    m/doc/36791581/NCP
    (12-20 bpm) breath sounds oxygen saturation
    -Ineffective-Airway-
    - (+) amount of and adventitious and if it develops
    Clearance
    yellowish sounds in desaturation
    secretions and indicates
    - GCS = 8 accumulation of
    - SpO2 = 87%
    secretions and
    5. Document inability to clear
    respiratory airways.
    secretions:
    (character, color) 5. To know the
    severity of the
    secretions

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