NCP: Ineffective Airway Clearance

Nursing Assessment

Johti Singh is a 39-year-old secretary who was admitted to  the hospital with an elevated temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been dieting for several months and skipping meals. Ms. Singh mentions that in addition to her full-time job as a secretary she is attending college classes two evenings a week. She has smoked one package of cigarettes per day since she was 18 years old. Chest x-ray confirms pneumonia.

Physical Examination          

Height: 167.6 cm (5960)        

Weight: 54.4 kg (120 lb)        

Temperature: 39.4°C (103°F)

Pulse: 68 beats/min     

Respirations: 24/min  

Blood pressure: 118/70 mmHg

Skin pale; cheeks flushed; Chills; use of accessory muscles; inspiratory crackles with diminished breath sounds right base; expectorating thick, yellow sputum.

 

Diagnostic Data

Chest X-ray: right lobar infiltration

WBC: 14,000

pH: 7.49

PaCo_2: 33 mmHg

HCO: 20 mmHg

PaO_2: 80 mmHg

O₂SAT: 88%

 

Nursing Diagnosis

Ineffective Airway Clearance related to thick sputum, secondary to pneumonia (as evidenced by rapid respirations, diminished and adventitious breath sounds, thick yellow sputum)
 

Desired Outcomes*

Respiratory Status: Airway Patency as evidenced by:

-No deviation from normal range for respiratory rate

-No accumulation of sputum

-No adventitious breath sounds

 

Nursing Interventions*      

Cough Enhancement (3250)

-Assist Ms. Singh to a sitting position with head slightly flexed, shoulders relaxed, and knees flexed.

-Encourage her to take several deep breaths.       

-Encourage her to take a deep breath, hold for 2 seconds, and cough two or three times in succession.       

  -Encourage use of incentive spirometry, as appropriate.       

-Promote systemic fluid hydration, as appropriate.  

 

Respiratory Monitoring (3350)

-Monitor rate, rhythm, depth, and effort of respirations.      

-Note chest movement, watching for symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.

-Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds.   

-Auscultate lung sounds after treatments to note results.     

-Monitor client’s ability to cough effectively.     

-Monitor client’s respiratory secretions.              

  -Institute respiratory therapy treatments (e.g., nebulizer) as needed.

-Monitor for increased restlessness, anxiety, and air hunger.    .

-Note changes in SpO2 and arterial blood gas values, as appropriate.
 

Evaluation

Outcome partially met. Ms. Singh coughs and deep breathes purposefully q1–2h during the day. Her fluid intake is approximately 1,500 ml each day. Cough continues to be productive of moderately thick, rusty-colored sputum. Inspiratory crackles remain present in right lower lobe.

*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions and activities se- lected are only a sample of those by NOC and NIC and should be further individualized for each client.