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San Pablo, Felma Jade N.

BSN206- Group 24-A NURSING CARE PLAN Assessment S: (not applicable since the client is unresponsive) O: Presence of secretions in mouth and tubing With brownish color of secretions In T-piece, with O2 of 4.5 L/min On ECG monitoring Nursing diagnosis Ineffective airway clearance related to secretions in the bronchi as manifested by presence of brownish secretions in the tubing, and RR=30 CPM Analysis Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. (Doenges et al, Nurses Pocket Guide, 11th Edition) Planning Goal: At the end of the shift, the client will be able to maintain a patent airway. Objectives: After 1 hour of nursing interventions, the client will be able to: - Have a clear secretion and with clear color. Intervention Rationale

Area: ICU-CCU C.I. Edcel L. Cortez


-at the end f the shift, does the client be able to have a patent airway? Yes or No? Why?


-provide adequate oxygenation

V/S: T= 34.5 C RR= 30 CPM

-Various therapies/modalities may be required to acquire /maintain -monitor adequate airways, respiration, improve respiratory oxygen function and gas saturation exchange. regularly (Doenges et al, Nurses Pocket th - monitor ECG Guide, 11 Edition, of patient page 79) -elevate head of -to take advantage the bed at 30 of gravity degrees decreasing pressure on the diaphragm and enhancing drainage

-does the client able to clear secretions and with clear color? Yes or No? Why?

of/ventilation to different lung segments. (Doenges et al, Nurses Pocket th Guide, 11 Edition, page 78-79) -position patient on head on the side and above the level of the heart. -to prevent vomiting with aspiration into the lungs (Doenges et al, Nurses Pocket Guide, 11th Edition, page 79) -Does the client be able to breathe adequately at a range of 12-20 CPM? Yes or No? Why?

-do suctioning -to clear airway every hour or as when excessive or needed viscous secretions are blocking airway or client is unable to swallow or cough effectively. (Doenges et al, Nurses Pocket th Guide, 11 Edition, page 78) -do bedside care Like checking of vital signs every 15mins -to monitor current status of clients condition and to note for any abnormalities such as infection (Doenges et al, Nurses Pocket th Guide, 11 Edition, page 78)

breath adequatel y at a range of 12-20 CPM

Collaborative: -do nebulization

-to help loosen secretion in the lungs

-do turning of -to prevent patient every 2 complication and hours pressure ulcer