Ineffective Airway Clearance

Published on Saturday March 10th , 2007

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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