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NURSING
DIAGNOSIS
Ineffective airway
clearance related
to retained
secretions
BACKGROUND
KNOWLEDGE
Ineffective airway clearance
is the inability to clear
secretions or obstructions
from the respiratory tract to
maintain a clear airway.
GOAL AND
OBJECTIVES
At the end of nursing
intervention, the client
will be able to:
Goal:
> Client will be able to
maintain adequate,
patent airway.
INTERVENTIONS AND
RATIONALE
Assess physical health level and
potential injuries and/or illnesses.
This will serve as a basis to avoid
worsening the clients condition
after the interventions.
Age: 77 y/o
Provision of enough
ventilation for the whole
body
Breath with ease without the
use of accessory muscles
Relieve shortness of breath
and difficulty breathing
Relieve chest pain
Prevent worse progression
of lung condition
EVALUATION
Standard
Criteria
hindi lumalabas
ang plema.
The client
verbalized loss of
appetite.
Objective cues:
Diagnosed with
Hospital-acquired
pneumonia.
Lower right lung
is full of
secretions as
shown on recent
chest x-ray.
Use of accessory
muscles for
breathing.
Low energy,
fatigue
In need of O2
support.
RR at rest on
bed: 26
Positive for rales
Circulate blood
Deliver enough oxygen to
the whole body
Avoid greater risk for
infections
Enumerates at least
2 consequences
of retained
secretions.
States drinking a
lot of water will
The client will be
help loosen the
able to determine
secretions.
the role of
hydration in
maintenance of
clear airway.
Demonstrates deep
breathing
exercises
correctly.
Verbalizes being
comfortable to
position.
frequently
invade
other
tissues and organs outside of
the bone marrow. During this
phase, the disease transforms
into an aggressive, acute
leukemia (70 percent acute
myelogenous leukemia, 30
percent acute lymphocytic
leukemia).
References:
- Carpenito, L. J. (2009).
Nursing diagnosis:
Application to Clinical
Practice .Philadelphia:
Wolters Kluwer
Health/Lippincott Williams &
Wilkins.
- Mayo Clinic (2015). Acute
Myelogenous Leukemia.
Retrieved from
http://www.mayoclinic.com/
- Mayo Clinic (2016).
Pneumonia. Retrieved from
http://www.mayoclinic
exercises
her.
discussed and
demonstrated by
Expectorates
the nurse.
The client will be
effectively after
able to
CP.
expectorate after
CP.
Demonstrates
proper airway
clearance
techniques.
Verbalizea relief
from airway
obstructions.