Ineffective Airway Clearance

Ineffective
Airway Clearance

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Atrificial airway
(_) Excessive or thick secretions
(_) Inability to cough effectively

(_) Infection
(_) Obstruction/restriction
(_) Pain
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Ineffective cough.
(_) Inability to remove airway secretions.
Minor:

(
May be
present
)
(_)
Abnormal breath sounds.
(_) Abnormal respiratory rate, rythm, depth.

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target
Date:
Nursing Interventions
[Check
those that apply]
Date

Achieved:

  The
patient will:

(_)
Maintain patent airway A.E.B.:

  • Clear breath
    sounds or breath sounds consistent with own
    baseline.
  • Respirations easy
    and un-labored.
  • Normal resp.
    rate.

(_) Other:

  (_)
Assess respiratory rate, depth, rythm, effort, and breath
sounds q ___ hours.

(_) Position: HOB elevated ___ degrees.

(_) Promote optimum
level of activity for best possible lung expansion:

  • Ambulate q ___
    for ___ min.
  • Chair q ___ for
    ___ min.
  • Turn/reposition q ___.

(_) Suction q ___
hours (and prn) per:

  • Nasal
  • Oral
  • Tracheal

(_) Encourage fluids
when indicated.

(_)
Other:________________

________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature