1) Ineffective Airway Clearance: Possibly evidenced by statement of difficulty breathing, changes in depth/rate of respirations, use of accessory muscles, abnormal breath sounds, persistent cough and sputum. More info in table below!
2) Impaired Gas Exchange: May be related to altered O2 supply, Alveoli destruction, and alveolar-capillary membrane changes. Evidenced by dyspnea, abnormal breathing, confusion, restlessness, inability to move secretions, hypoxia, hypercapnia, changes in vital signs, and activity intolerance.
3) Imbalanced Nutrition: May be related to dyspnea, sputum production, medication side effects, fatigue. Possibly evidenced by weight loss, loss of muscle mass, poor muscle tone, reported altered taste sensation, aversion to eating, and lack of interest in food.
4) Risk for Infection: Risk factors include inadequate primary defenses, inadequate acquired immunity, chronic disease process, and malnutrition.
5) Knowledge Deficit: May be related to lack of information/unfamilarity with resources, misinterpretation and lack of recall cognition. Evidenced by patient requesting information, statement of concerns/misconceptions, inaccurate follow-through of instructions, and development of preventable complications.
| Nursing Diagnosis | Ineffective Airway Clearance | |
|---|---|---|
| Actual or Potential | -Potential | |
| Related to | -Broncospasm -Increased production of secretions; retained secretions; thick, viscous secretions -Allergic airways -Hyperplasia of bronchial walls -Decreased energy/fatigue | |
| Plan and Outcome | -Maintain airway patency with breath sound clear/clearing -Demonstrate behaviors to improve airway clearance (cough effectively, expectorate secretions) | |
| Nursing Intervention |
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This website is my favorite and is the most clear about the different nursing care diagnosess and interventions. It is longer and in-depth, however very organized and extremely easy to read!
NurseLabs.com
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