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  • Ineffective Airway Clearance Careplan

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    derresha
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    1. Collaborative interventions were provided to improve ineffective airway clearance in an intubated patient, including positioning in fowlers position, suctioning, providing fluids and medications like mucolytics. 2. After 30 minutes the patient showed improvement in airway clearance as evidenced by minimal thin clear secretions suctioned from the endotracheal tube and stable vital signs. 3. The interventions helped remove secretions, maintain airway permeability, provide oxygenation, and reduce the risk of infection while monitoring the patient's response.

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    care plan

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    1. Collaborative interventions were provided to improve ineffective airway clearance in an intubated patient, including positioning in fowlers position, suctioning, providing fluids and medications like mucolytics. 2. After 30 minutes the patient showed improvement in airway clearance as evidenced by minimal thin clear secretions suctioned from the endotracheal tube and stable vital signs. 3. The interventions helped remove secretions, maintain airway permeability, provide oxygenation, and reduce the risk of infection while monitoring the patient's response.

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    68 views6 pages

    Ineffective Airway Clearance Careplan

    Uploaded by

    derresha
    1. Collaborative interventions were provided to improve ineffective airway clearance in an intubated patient, including positioning in fowlers position, suctioning, providing fluids and medications like mucolytics. 2. After 30 minutes the patient showed improvement in airway clearance as evidenced by minimal thin clear secretions suctioned from the endotracheal tube and stable vital signs. 3. The interventions helped remove secretions, maintain airway permeability, provide oxygenation, and reduce the risk of infection while monitoring the patient's response.

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    © All Rights Reserved
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    of 6

    Wash hands or perform hand hygiene before having contact with te patient

    R: Friction, soap and running water remove microganism from the hand effectively

    Risk for atient


    Infection: AEB remains free
    Dressing noted of infection,
    to the hip and as evidenced
    leg, urinary by normal
    catheter,
    vital signs and
    absence of
    signs and
    symptoms of
    infection.
    Need: Oxygen
    Assessment Diagnosis Patient Interventions Rationales Evaluation
    Outcome

    Subjective Data: Ineffective At the end of 1.Position 1.This will After 30


    . GCS 3t/15 (E1 airway 30 minutes patient in promote minutes,
    V1 M1) clearance following semi or high oxygenation following
    . Patient unable related to collaborative fowlers to allow for collaborative
    to speak patient’s interventions, position. maximum care, patient
    because he is inability to patient will (Endsjo, chest showed an
    intubated and clear experience an 2017) expansion improvement in
    on mechanical secretions improvement without the airway
    ventilation. from airway in airway 2.Suction effects of clearance as
    as evidence clearance as patient as gravity as evidence by
    Objective Data: by patient evidence by ordered by gravity pulls minimal thin
    . No cough being minimal thin physician or the clear secretions
    reflex intubated, on clear mucous PRN. (Heidari diaphragm suctioned from
    . While spontaneous suctioned and & Shahbazi, downwards, ET Tube and
    suctioning, ventilation, a reduction in 2017) allowing for vital signs
    moderate has no cough vital signs expansion P98bpm,
    amount of thick reflex, especially 3. Provide and R20bpm,
    clear mucous moderate pulse fluids such as ventilation. BP130/80mmHg
    secretions were amount of between 60- 0.9% Normal (Endsjo, and SpO2
    suctioned from thick clear 100bpm, Saline as 2017) remained at
    endotracheal mucous seen respiration ordered. 100%
    tube while 12-20bpm, BP (Castera & 2.This is done
    . On mechanical suctioning 120-130/70- Borhade, to remove
    ventilation. and vital signs 80mmHg and 2021) accumulated
    . Diagnosis: P11bpm, SpO2 remains lung
    Sinonasal R28bpm and at 100% 4.Medicate secretions in
    undifferentiated BP patient as order to
    Carcinoma 142/95mmHg ordered with maintain the
    . Vital signs mucolytics airway's
    P114bpm (Bisolvon) permeability,
    R28bpm and normal provide
    BP saline nebs. adequate
    142/95mmHg (Leader, oxygenation,
    2020) reduce the
    risk of
    5.Advocate Ventilator-
    for patient to Associated
    be placed on Pneumonia
    humidified (VAP) and to
    oxygen. prevent
    (Nurseslab, pulmonary
    2020) consolidation
    and
    6.Monitor atelectasis.
    (Heidari &
    vital signs Shahbazi,
    especially 2017)
    pulse,
    respiration, 3.This is to
    BP and SpO2. keep the
    (Nurseslabs, patient
    2020) hydrated as
    well as it will
    help to soften
    secretions
    making it easy
    to be
    removed,
    helps to
    stabilize an
    increase in
    vital signs
    (pulse
    (tachycardia),
    respiration,
    BP) which can
    be early signs
    of
    hypovolemic
    shock, helps
    increase urine
    output,
    moistens
    mucous
    membranes.
    (Castera &
    Borhade,
    2021)

    4.This helps
    to break up
    and think
    mucous,
    making it
    easier to be
    cleared from
    the airways.
    (Leader,
    2020)

    5. Increasing
    humidity of
    inspired air
    will reduce
    thickness of
    secretions
    and aid their
    removal.
    (Nurseslab,
    2020)

    6.This will,
    along with
    knowing the
    baseline
    vitals, will
    indicate if
    there is any
    improvement
    in the
    patient’s
    condition or if
    it has gotten
    worse.
    (Nurseslab,
    2020)

    Reference

    Castera, M., & Borhade, M. (2021). Fluid Management. Retrieved 30 May 2021, from
    https://www.ncbi.nlm.nih.gov/books/NBK532305/#_NBK532305_pubdet_

    Endsjo, A. (2017). Fowler’s Position: Beyond the Bed. Retrieved 30 May 2021, from
    https://hub.permobil.com/blog/fowlers-position-beyond-the-bed

    Heidari, M., & Shahbazi, S. (2017). Nurses' Awareness about Principles of Airway Suctioning. JOURNAL
    OF CLINICAL AND DIAGNOSTIC RESEARCH. doi: 10.7860/jcdr/2017/25550.10452

    Ineffective Airway Clearance – Nursing Diagnosis & Care Plan. (2020). Retrieved 30 May 2021, from
    https://nurseslabs.com/ineffective-airway-clearance/

    Leader, D. (2020). How Effective Are Mucolytics in Treating COPD?. Retrieved 30 May 2021, from
    https://www.verywellhealth.com/mucolytics-definition-and-example-copd-914793

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