306 UNIT IV / The Nursing Process
NURSING CARE PLAN FOR AMANDA AQUILINI
NURSING DIAGNOSIS:
INEFFECTIVE AIRWAY CLEARANCE
RELATED TO VISCOUS SECRETIONS AND
SHALLOW CHEST EXPANSION SECONDARY TO FLUID VOLUME DEFICIT, PAIN, AND FATIGUE
GOALS [NOC#]/
DESIRED OUTCOMES NURSING ORDERS RATIONALE
Respiratory Status: Gas Monitor respiratory status q4h: rate, To identify progress toward or deviations
exchange [0402], as depth, effort,skin color, mucous from goal. Ineffective Airway Clearance
evidenced by membranes, amount and color of leads to poor oxygenation, as evidenced by
•Absence of pallor and sputum. pallor,cyanosis, lethargy,and drowsiness.
cyanosis (skin and Monitor results of blood gases, chest
mucous membranes) x-ray studies, and incentive
•Use of correct breathing/ spirometer volume as available.
coughing technique after Monitor level of consciousness.
instruction Auscultate lungs q4h. Inadequate oxygenation causes increased
•Productive cough Vital signs q4h (TPR, BP, pulse rate. Respiratory rate may be decreased by
•Symmetric chest excur- pulse oximetry). narcotic analgesics. Shallow breathing further
sion of at least 4 cm compromises oxygenation.
Within 48-72 hours
•Lungs clear to auscultation Instruct in breathing and coughing To enable client to cough up secretions.
•Respirations 12-22/min; techniques. Remind to perform,and May need encouragement and support
pulse, 100 beats/min assist q3h. because of fatigue and pain.
•Inhales normal volume
of air on incentive spirometer Administer prescribed expectorant; Helps loosen secretions so they can
schedule for maximum effectiveness. be coughed up and expelled.
Maintain Fowler’s or semi-Fowler’s Gravity allows for fuller lung expansion
position. by decreasing pressure of abdomen on
diaphragm.
Administer prescribed analgesics. Controls pleuritic pain by blocking
Notify physician if pain not relieved. pain pathways and altering perception
of pain, enabling client to increase
thoracic expansion. Unrelieved pain may
signal impending complication.
Administer ox ygen by nasal cannula Supplemental oxygen makes more oxygen
as prescribed. Provide portable available to the cells,even though
oxygen if client goes off unit less air is being moved by the client,
(e.g., for x-ray examination). thereby reducing the work of breathing.
Assist with postural drainage daily at Gravity facilitates movement of secretions
0930. upward through the respiratory passage.
Administer prescribed antibiotic to Resolves infection by bacteriostatic or
maintain constant blood level. bactericidal effect, depending on type of
Observe for rash and GI or other antibiotic used.Constant level required to
side effects. prevent pathogens from multiplying.
Allergies to antibiotics are common.
continued
The following criteria can help the nurse choose the best
nursing interventions. The plan must be
•Safe and appropriate for the individual’s age, health, and condition.
•Achievable with the resources available. For example, a
home care nurse might wish to include a nursing order for
an elderly client to “Check blood glucose daily”; but in or-
der for that to occur, either the client must have intact sight,
cognition, and memory to carry this out independently, or
daily visits from a home care nurse must be available and
affordable.
•Congruent with the client’s values, beliefs, and culture.
