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Ineffective Airway Clearance

The patient is experiencing difficulty breathing due to asthma exacerbation. Asthma is characterized by inflammation of the bronchial tubes causing constriction and excess mucus production. The nurse's goals are to monitor the patient's vital signs and respiratory status, clear mucus secretions through positioning, deep breathing exercises, and back tapping, and help the patient relax to improve breathing and rest. The evaluation will assess whether the patient's airway remains clear and breathing has calmed after the interventions.

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4K views1 page

Ineffective Airway Clearance

The patient is experiencing difficulty breathing due to asthma exacerbation. Asthma is characterized by inflammation of the bronchial tubes causing constriction and excess mucus production. The nurse's goals are to monitor the patient's vital signs and respiratory status, clear mucus secretions through positioning, deep breathing exercises, and back tapping, and help the patient relax to improve breathing and rest. The evaluation will assess whether the patient's airway remains clear and breathing has calmed after the interventions.

Uploaded by

jomerdalona
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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PROBLEM SCIENTIFIC BASIS GOAL OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTION
S: “Sir, ma-feel jud nako
The basic Within my 8 hr. span of Independent After my nursing
nga nay plema sa sulod characteristics of care, the pt. will be interventions, the
kay hagalkal man taga- asthma able to maintain patent - Monitor vital -to note blood patient was able to
ubo nakopero dili nako (inflammation of airway as evidenced signs pressure and pulse maintain patent
mapagawas tanan” as bronchial mucosa, by: changes indicating airway as evidenced
verbalized by the constriction of the respiratory distress by:
patient. bronchiolar smooth  Absence of  Absence of
muscle, and signs of -Monitor -Indicative of signs of
thickened respiratory respiration and respiratory distress respiratory
O: secretions) distress breath sounds, and/or distress
 RR from 26 to decrease the  Diminish noting rate and accumulation of  Diminished
32 cpm diameter of the abnormal breath sounds secretions, monitor abnormal
 Dyspnea bronchi and occur in sounds effectiveness of breath sounds
 Use of accessory status asthmaticus.  Expectoration of intervention  Expectoration
muscles The most common mucus of mucus
 (+) wheezing scenario is severe secretions -Evaluate client’s -to determine the secretions
 (+) crackles bronchospasm, with  Calm and relax cough/gag reflex ability to protect  Calm and
 Productive cough mucus plugging appearance and swallowing airway relax
leading to asphyxia. ability appearance
 Restlessness
As asthma
exacerbation begin -Position client -to maximize lung
abruptly but most into semi- expansion
A: Ineffective airway
frequently is fowler’s position
clearance r/t retained
preceded by
mucus secretions
increasing - Encourage -to relieve dyspnea
secondary to Bronchial
symptoms over the deep breathing and maximize
Asthma.
previous few days. and coughing effort, also to help
There is cough, with exercises the patient become
or without mucus relax
production. At times,
the mucus is so
tightly wedged in the -Perform back -to loosen the
narrowed airway tapping mucus secretions
that the patient for easy
cannot cough it up. expectoration

-Observe signs -to identify


Reference: and symptoms of infectious process
Smeltzer, et.al., infection
2008, Brunner and
Suddarth’s Textbook -Provide calm -to promote rest
of Medical-Surgical and quiet and good sleep

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