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

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