Please help with Care plan for ineffective airway clearance..I'm stuck on goals!!

Nursing Students Student Assist


my pt is an 86 yom who is in for bil aspiration pna, resp failure, cad with pos troponin, acute renal insuff. iv vol depletion. he is demented ox3 does not respond to verbal or tactile stimuli has hx of htn, dm 2, s/p peg tube placement, copd, anemia, debility. o2 sats remain btwn 94-98 with 2l continuous o2 per nasal cannula. he is bed rest as well..

ineffective airway clearance r/t excessive mucus and inability to cough effectively s/t bilateral aspiration pneumonia and copd aeb pt has crackles in rul, wheezing in lul and lll and diminished breath sounds throughout lung fields

i need help with goals as i cannot teach incentive spirometer use, effective coughing techniques because he is demented and ox3 and he is not cyanotic at the moment so i cannot use cyanotic free skin

these are the only goals i have..

1. pt will maintain patent airway throughout shift ending at 6 pm 9/30/10


  • respiratory rate in expected range (12-20)
  • moves sputum out of airway
  • free of adventitious breath sounds


patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths

2. pt will demonstrate effective coughing and clear breath sounds by


  • auscultate the lungs for diminished, absent and adventitious breath sounds throughout shift--pt has crackles in rul, wheezing in lul and lll and diminished breath sounds throughout lung fields

  • give oxygen, bronchodilators, mucolytics, expectorants and antibiotics as ordered and as needed--pt has scheduled albuterol sulfate q and zosyn

  • reposition the pt at least once every two hours to optimize respirations. position the pt with the hob upright at least 45 degrees at all times-

  • ensure pt is getting adequate fluid intake so that he is staying hydrated and liquefying secretions- pt has hx of intravenous volume depletion and is tube fed

  • suction as needed- pt is demented, 0x3 and has depressed cough reflex so suction is necessary when needed

  1. monitor blood gas values and pulse oxygen saturation levels-pt has pulse oximeter taped to finger for continuous monitoring

Specializes in Psych.

As far as outcomes, I like #1 best and I think your interventions are great. Are you required to have an education intervention? I know it is difficult to do education with clients with dementia. Maybe you could at least do deep breathing with him. Is he cognizant enough to cooperate with requests from staff? If he is you can at least as him to try taking some nice deep breaths. You will probably have to remind him to do it again throughout the shift.

Thanks for the input!! He cannot follow commands from staff which makes it hard for education.. that's why I was stuck. I guess there is really nothing you can do to teach a pt that cannot respond to staff.

Thanks again!

+ Add a Comment