Nursing Care Plan: Managing Airway Clearance Post-Thoracotomy

Nursing Diagnosis: Ineffective Airway Clearance related to secretions, retained mucus plugs, or mechanical ventilation.

Goals:

- The client will maintain a patent airway.

- The client will be able to expectorate secretions effectively.

Interventions:

1. Assess respiratory status: Note rate, depth, and effort of respirations; presence of dyspnea, tachypnea, retractions, or use of accessory muscles; and breath sounds.

2. Encourage coughing and deep breathing: Instruct the client to cough and deep breathe every 1-2 hours while awake. Provide incentive spirometry as needed to assist with deep breathing.

3. Administer mucolytic agents: If prescribed, administer mucolytic agents to help loosen secretions.

4. Hydrate the client: Encourage the client to drink plenty of fluids to help thin secretions.

5. Perform postural drainage: If prescribed, perform postural drainage to help drain secretions from the lungs.

6. Suction the airway: If the client is unable to expectorate secretions effectively, suction the airway as needed.

7. Monitor oxygen saturation: Monitor oxygen saturation levels and administer supplemental oxygen as needed to maintain saturation above 90%.

Evaluation:

The client will achieve the goals of maintaining a patent airway and being able to expectorate secretions effectively as evidenced by:

- Respiratory rate, depth, and effort within normal limits

- Absence of dyspnea, tachypnea, retractions, or use of accessory muscles

- Clear breath sounds

- Ability to expectorate secretions effectively

- Oxygen saturation levels above 90%