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Airway Clearance Nursing Assessment Guide

The client presented with difficulty breathing, coughing up blood and sputum. [1] The nurse observed respiratory status and worked to improve airway clearance through positioning, deep breathing exercises and coughing. [2] The goals were for the client to demonstrate improved airway clearance within 30 minutes and maintain a patent airway long term by participating in treatment. [3] Interventions were aimed at opening airways, promoting secretion clearance and identifying potential complications.

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Dianne Parungao
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92 views2 pages

Airway Clearance Nursing Assessment Guide

The client presented with difficulty breathing, coughing up blood and sputum. [1] The nurse observed respiratory status and worked to improve airway clearance through positioning, deep breathing exercises and coughing. [2] The goals were for the client to demonstrate improved airway clearance within 30 minutes and maintain a patent airway long term by participating in treatment. [3] Interventions were aimed at opening airways, promoting secretion clearance and identifying potential complications.

Uploaded by

Dianne Parungao
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 DOCX, PDF, TXT or read online on Scribd

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Short Term Goal: • Observe respiratory • Presence After 30 minutes
airway status, patient’s ability of these symptoms of nursing
“Nahihirapan Clearance After 30 minutes to maintain airway, may indicate intervention,
ako huminga at related to of nursing work of breathing, impending the client
inuubo po ako na blood intervention,the client nasal flaring, pursed- respiratory failure
may kasamang dugo secretions will lip breathing, and Demonstrated
”as verbalized by prolonged expiratory • Positioning behaviors to
the patient ” • Demonstrate phase. helps maximize improve/maintain
behaviors to lung expansion and airway clearance
improve/maintain • Place client in semi decreases
Objective: airway clearance or high fowlers respiratory effort Identify potential
Position assist client Maximal ventilation complications and
• Presence with coughing and may open atelectatic initiate appropriate
of sputum • Identify potential deep breathing areas actions
with and complications and exercises. and promote
blood initiate appropriate movement
actions of secretions into
• Difficulty • Auscultate lung larger airways
of breathing Long Term Goal: fields’ hours and prn. for expectoration.
Notify physician
• Body • Maintain patent for significant changes •Expiratory
weakness Airway wheezing or ronchi
cough may be heard as
Participate in secretions and
treatment air move through the
regimen,within the narrowed airways.
level of ability Decreased breath
sounds throughout
the lung fields is a
critical sign
because it means
the patient cannot
move enough air to
be heard by the
clinician and
oxygenation and

• Helps to maintain
hydration to allow for
thinning of secretions

•High fluid intake


helps thin
secretions, making
them easier to
expectorate

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