Page 3 - PNEUMONIA NURSING CARE PLAN

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INEFFECTIVE AIRWAY CLEARANCE

This diagnosis is related to excessive secretions and ineffective cough or non-productive coughing.
Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway.

Related Factors
• Tracheal bronchial inflammation, oedema formation, increased sputum production
• Pleuritic pain
• Decreased energy, fatigue
• Aspiration
Assessment

• Changes in rate, depth of respirations
• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)
• Use of accessory muscles
• Dyspnea, tachypnea
• Cough, effective or ineffective; with/without sputum production
• Cyanosis
• Decreased breath sounds over affected lung areas
• Ineffective cough
• Purulent sputum
• Hypoxemia
• Infiltrates seen on chest x-ray film

Goals and outcomes

• Patient will identify / demonstrate behaviors to achieve airway clearance.
• Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as
evidenced by keeping a patent airway and effectively clearing secretions.

Nursing Interventions and Rationale

Nursing Interventions Rationale

Assessment

Tachypnea, shallow respirations and asymmetric
chest movement are frequently present because of
Assess the rate, rhythm, and depth of discomfort of moving chest wall and/or fluid in
respiration, chest movement, and use of lung due to a compensatory response to airway
accessory muscles. obstruction. Altered breathing pattern may occur
together with use of accessory muscles to increase
chest excursion to facilitate effective breathing.

Coughing is the most effective way to remove
Assess cough effectiveness and
productivity secretions. Pneumonia may cause thick and
tenacious secretions to patients.

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