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    Cues/Clues Nursing Diagnosis Plan Intervention Rationale Evaluation

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    Christine Ibias
    1. The patient has ineffective airway clearance related to an inability to remove secretions as evidenced by cough for 3 days and bilateral crackles on auscultation. 2. The plan is to perform nasotracheal suctioning within 8 hours and teach the patient proper coughing and breathing techniques to enhance secretion removal. 3. After 8 hours of nursing intervention, the evaluation is that the patient maintained clear, open airways as evidenced by normal respiration and an ability to cough up secretions effectively after treatment.

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    Cues/Clues Nursing Diagnosis Plan Intervention Rationale Evaluation

    Uploaded by

    Christine Ibias
    144 views1 page
    1. The patient has ineffective airway clearance related to an inability to remove secretions as evidenced by cough for 3 days and bilateral crackles on auscultation. 2. The plan is to perform nasotracheal suctioning within 8 hours and teach the patient proper coughing and breathing techniques to enhance secretion removal. 3. After 8 hours of nursing intervention, the evaluation is that the patient maintained clear, open airways as evidenced by normal respiration and an ability to cough up secretions effectively after treatment.

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    NCP

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    1. The patient has ineffective airway clearance related to an inability to remove secretions as evidenced by cough for 3 days and bilateral crackles on auscultation. 2. The plan is to perform nasotracheal suctioning within 8 hours and teach the patient proper coughing and breathing techniques to enhance secretion removal. 3. After 8 hours of nursing intervention, the evaluation is that the patient maintained clear, open airways as evidenced by normal respiration and an ability to cough up secretions effectively after treatment.

    Copyright:

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

    Cues/Clues Nursing Diagnosis Plan Intervention Rationale Evaluation

    Uploaded by

    Christine Ibias
    1. The patient has ineffective airway clearance related to an inability to remove secretions as evidenced by cough for 3 days and bilateral crackles on auscultation. 2. The plan is to perform nasotracheal suctioning within 8 hours and teach the patient proper coughing and breathing techniques to enhance secretion removal. 3. After 8 hours of nursing intervention, the evaluation is that the patient maintained clear, open airways as evidenced by normal respiration and an ability to cough up secretions effectively after treatment.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    CUES/CLUES NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE EVALUATION

    1. Perform nasotracheal suctioning. 1. Suctioning is needed


    Subjective: Ineffective Airway Clearance Within 8 hours of when patients are unable After 8 hours of nursing
    -Cough for 3 days related to Inability to remove nursing intervention the to cough out secretions intervention the patient:
    secretions as evidenced by patient will: properly due to weakness,
    ineffective cough thick mucus plugs, or 1. Maintained clear, open
    Objective: 1. Maintain clear, open excessive or tenacious airways as evidenced by
    -Bilateral Crackles upon airways. mucus production. normal rate and depth of
    auscultation 2. The most convenient respirations, and ability to
    2. Classify methods to 2. Teach patient the proper ways of coughing way to remove most effectively cough up
    enhance secretion and breathing. Include: secretions is coughing. secretions after treatment
    removal -Sit in optimal position So, it is necessary to and deep breaths.
    -Taking a deep breath, hold for 2 seconds, assist the patient during
    and cough two or three times in succession. this activity. Deep 2. Classified methods to
    -Use of pillow or hand splints when coughing breathing, on the other enhance secretion removal.
    -Use of abdominal muscles for more forceful hand, promotes
    cough oxygenation.
    -Use of quad and huff techniques -Proper sitting position
    -Use of incentive spirometry and splinting abdomen
    -Importance of ambulation and frequent promote effective
    position changes coughing by increasing
    abdominal pressure and
    upward diaphragmatic
    movement.
    -Controlled coughing
    methods help mobilize
    secretions from smaller
    airways to larger airways
    because coughing is done
    at varying times.
    -Ambulation promotes
    lung expansion, mobilizes
    secretions, and lessens
    atelectasis.

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