Nursing diagnosis: ineffective airway clearance related to tracheal bronchial inflammation, edema formation, increased sputum production; pleuritic pain; decreased energy, fatigue.
Possibly evidenced by
Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles
Cough, effective or ineffective; with or without sputum production
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Identify and demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis.
Nursing care plan intervention with rationale:
1. Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure; for example, cyanosis and severe tachypnea.
Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear.
2. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.
Rationale: Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction.
3. Elevate head of bed; change position frequently.
Rationale: Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear.
4. Assist client with frequent deep-breathing exercises. Demonstrate and help client, as needed; learn to perform activity, such as splinting chest and effective coughing while in upright position.
Rationale: Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Note: Cough associated with pneumonias may last days, weeks, or even months.
5. Suction, as indicated; for example, oxygen desaturation related to airway secretions.
Rationale: Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough or decreased level of consciousness.
6. Force fluids to at least 2,500 mL per day, unless contraindicated, as in HF. Offer warm, rather than cold, fluids.
Rationale: Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.
7. Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, such as incentive spirometer, intermittent positive-pressure breathing (IPPB), percussion, and postural drainage. Perform treatments between meals and limit fluids when appropriate.
Rationale: Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations.
8. Administer medications, as indicated, for example mucolytics, expectorants, bronchodilators, and analgesics.
Rationale: Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.
9. Provide supplemental fluids such as IV, humidified oxygen, and room humidification.
Rationale: Fluids are required to replace losses, including insensible, and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
10. Monitor serial chest x-rays, ABGs, and pulse oximetry readings.
Rationale: Follows progress and effects of disease process and therapeutic regimen, and facilitates necessary alterations in therapy.