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Ineffective Airway Clearance
Ineffective Airway Clearance
(_)Actual (_) Potential
| (_)
Atrificial airway (_) Excessive or thick secretions (_) Inability to cough effectively (_) Infection (_) Obstruction/restriction (_) Pain (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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.:
(_) 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:
(_) Suction q ___ hours (and prn) per:
(_) Encourage fluids when indicated. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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