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    Ineffective Airway Clearance NCP

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    Benz ParCo
    - The patient presented with difficulty breathing and productive cough. Nursing assessment found pale appearance, dyspnea, use of accessory muscles for breathing, and respiratory rate of 41 cycles per minute. - The nursing diagnosis was ineffective airway clearance related to secretions in the bronchi. The pathophysiology involved irritant inhalation causing inflammatory response and increased secretions. - The short term goal was to maintain airway patency and reduce congestion through various nursing interventions over 4 hours. The long term goal was to decrease the respiratory rate to 12-20 cycles per minute over 2 days.

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    Ineffective Airway Clearance NCP

    Uploaded by

    Benz ParCo
    2K views1 page
    - The patient presented with difficulty breathing and productive cough. Nursing assessment found pale appearance, dyspnea, use of accessory muscles for breathing, and respiratory rate of 41 cycles per minute. - The nursing diagnosis was ineffective airway clearance related to secretions in the bronchi. The pathophysiology involved irritant inhalation causing inflammatory response and increased secretions. - The short term goal was to maintain airway patency and reduce congestion through various nursing interventions over 4 hours. The long term goal was to decrease the respiratory rate to 12-20 cycles per minute over 2 days.

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    Ineffective Airway Clearance Ncp

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    - The patient presented with difficulty breathing and productive cough. Nursing assessment found pale appearance, dyspnea, use of accessory muscles for breathing, and respiratory rate of 41 cycles per minute. - The nursing diagnosis was ineffective airway clearance related to secretions in the bronchi. The pathophysiology involved irritant inhalation causing inflammatory response and increased secretions. - The short term goal was to maintain airway patency and reduce congestion through various nursing interventions over 4 hours. The long term goal was to decrease the respiratory rate to 12-20 cycles per minute over 2 days.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    2K views1 page

    Ineffective Airway Clearance NCP

    Uploaded by

    Benz ParCo
    - The patient presented with difficulty breathing and productive cough. Nursing assessment found pale appearance, dyspnea, use of accessory muscles for breathing, and respiratory rate of 41 cycles per minute. - The nursing diagnosis was ineffective airway clearance related to secretions in the bronchi. The pathophysiology involved irritant inhalation causing inflammatory response and increased secretions. - The short term goal was to maintain airway patency and reduce congestion through various nursing interventions over 4 hours. The long term goal was to decrease the respiratory rate to 12-20 cycles per minute over 2 days.

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    Assessment Pathophysiology Planning Intervention Rationale Evaluation

    Short Term Goal


    Subjective Irritant Dx
    Short Term Goal - After 4 hours of
    - “Hindi ko mailabas ung (inhalation) - Vital signs monitored > for baseline comparison nursing
    -  After 4 hours of intervention, the
    ibang plegma,” as Nursing intervention, and recorded. goal is met through
    inflammatory airway patency will maintenance of
    verbalized. be - Assisted in semi- > proper positioning helps in airway patency and
    response maintained, draining secretions reduction in
    Objective secretions will be Fowler’s position.
    congestion.
    readily expectorated
    - pale in appearance - Encouraged deep > This will promote proper
    increase production of and there will be Long Term Goal
    lung expansion
    - dyspnea signs of reduction in breathing exercise
    secretions - After 2 days of nursing
    congestion.
    intervention, the goal is
    -  uses accessory muscles Tx
    Long Term Goal met through decreased in
    - Bedside care done > For Proper hygiene
    when breathing respiratory rate of 14
    airway constriction
    - After two days the cylces per minute.
    - Established rapport > For patient nurse
    - productive cough clients respiratory interaction
    rate will be 12 – 20
    - RR=41 cycles per minute dyspnea cycles per minute. - Administered prescribed >Prescribed meds such as
    medications bronchodilators helps in
    Nursing Diagnosis: aiding effective airway
    -Ineffective airway clearance
    clearance related to - Provided supplemental > Nebulization helps in
    secretions in the bronchi humidification via use of liquefy secretions for faster
    nebulizer expectorating of secretions
    Ex

    - Encouraged client to > to liquefy the secretions for


    increased fluid intake better patency

    - Encouraged client to > to reduce congestion


    expectorate secretions

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