Wednesday, January 11, 2012

Ineffective Airway Clearance Stroke Nursing Care Plan

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Stroke

Stroke is also Referred to as a brain attack, and it Occurs Pls a blood vessel leading to the brain ruptures or gets blocked due to plaque deposits. When plaque accumulates on the wall of arteries, it is known as arthrosclerosis.

Nanda Nursing Diagnosis Ineffective Airway Clearance

related to the buildup of sputum (due to weakness, loss of cough reflex)

Goal: Patient is able to maintain a patent airway.

Expected outcomes:

a. Vesicular breath sounds

b. Normal respiratory rate

c. No signs of cyanosis and pallor

d. There is no sputum

Nursing Interventions :

1. Auscultation of breath sounds

2. Measure vital signs

3. Give the semi-Fowler position in accordance with the requirements (not conflict with other nursing problems)

4. Perform the exploitation lenders and pairs of OPA if decreased consciousness

5. When it is possible to do chest physiotherapy and breathing exercises in

6. Collaboration:
  • Provision of oxygenation
  • Laboratory: blood gas analysis, complete blood etc.
  • Giving medication as needed
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