Alyssa Loise B.

Acosta EAMC 3rd Shift

IV-NUR-1 RLE 1 Maam Terre

NCP for Ineffective Airway Clearance

Assessment Nursing Scientific Rationale Objectives/Goals Nursing Rationale Evaluation

Diagnosis Interventions
Objective: Ineffective Airway Normally the lungs are Within 3-4 hours of 1. Assessed 1. Provides a basis
- On endotracheal Clearance related free from secretions. nursing interventions, respiratory rate for evaluating
tube attached to to excessive Pneumonia bacteria the patient will be able and chest adequacy of
a mechanical mucus secretions are invading the lung to: movement ventilation and
ventilator with as manifested by parenchyma thus, Have patent airway indicate response
the following desaturation and producing Expectorate retained to ineffective
settings: FiO2 = increase in inflammatory process. yellowish ventilation
100%, VT = respiration And these responses secretions 2. Maintained on
320, AC mode, leading to filling of semi-fowlers 2. Positioning helps
BUR = 16/28, the alveolar sacs with position maximize lung
3. Suctioned
PEEP = 10 exudates leading to expansion
- (+) crackles on patient limited to 3. To maintain
consolidation.
both lung fields 5-sec duration adequate airway
- Labored 4. Monitor changes
Source: patency
breathing in SpO2.
https://www.scribd.co
- RR = 31 bpm Auscultate 4. To know the
m/doc/36791581/NCP
(12-20 bpm) breath sounds oxygen saturation
-Ineffective-Airway-
- (+) amount of and adventitious and if it develops
Clearance
yellowish sounds in desaturation
secretions and indicates
- GCS = 8 accumulation of
- SpO2 = 87%
secretions and
5. Document inability to clear
respiratory airways.
secretions:
(character, color) 5. To know the
severity of the
secretions