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Nursing Care Plan for Ineffective Airway Clearance related to Rhinosinusitis


Rhinosinusitis is an inflammatory disease mucosal lining of the nose and paranasal sinuses. This inflammation often stems from a viral infection, which is due to certain circumstances evolve into a bacterial infection with bacterial pathogens that cause contained in the upper airway. Another cause is a fungal infection, dental infections, and can also occur as a result of fractures and tumors (Benninger and Gottschall, 2006; Soetjipto et al, 2006).


Nursing Diagnosis for Rhinosinusitis : Ineffective Airway Clearance related to excessive mucus.

NOC :
  • Respiratory status : Ventilation
  • Respiratory status : Airway patency
  • Aspiration Control
Expected outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, was able to breathe easily, no pursed lips).
  • Indicates that a patent airway (the client does not feel suffocated, the rhythm of breathing, respiratory frequency in the normal range , no abnormal breath sounds).
  • Being able to identify and prevent the factors that can inhibit airway.

NIC :

Airway Management
  • Open the airway, use techniques chin lift or jaw thrust if necessary.
  • Position the patient to maximize ventilation.
  • Identification of the patient's need for installation tools artificial airway.
  • Installing mayo if necessary.
  • Perform chest physiotherapy if necessary.
  • Remove secretions by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on the mayo.
  • Give bronchodilators if necessary.
  • Give humidifier wet gauze, with NaCl moist.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status.
Airway Suction
  • Ensure the needs of oral / tracheal suctioning.
  • Auscultation of breath sounds before and after suctioning.
  • Inform the client and family about suctioning.
  • Ask the client a deep breath before suction done .
  • Give O2 by using a nasal, to facilitate nasotracheal suction.
  • Use sterile tools every action.
  • Instruct the patient to rest and deep breath, after the catheter is removed from the nasotracheal.
  • Monitor the status of the patient oxygen.
  • Teach the patient's family, how to perform suction.
  • Stop suction and administer oxygen if the patient showed bradycardia, increase in O2 saturation, etc.

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