Nursing diagnosis – ineffective airway clearance

Inneffective Airway Clearance
DEFINITION
Inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway
DEFINING CHARACTERISTICS
• INEFFECTIVE AIRWAY CLEARANCE
• Adventitious breath sounds,
such as crackles, rhonchi, and
wheezes
• Changes in respiratory rate
and rhythm
• Cyanosis
• Diminished breath sounds
• Difficulty vocalizing
• Dyspnea
• Ineffective or absent cough
• Orthopnea
• Restlessness
• Sputum production
• Wide-eyed
RELATED FACTORS
• Environmental: second-hand smoke, smoke inhalation, smoking
• Physiological: allergic airways, asthma, chronic obstructive
pulmonary disease, infection, neuromuscular dysfunction, and
hyperplasia of the bronchial walls
• Obstructed airway: airway spasm, excessive mucus, exudate in the
alveoli, foreign body in airway, presence of artificial airway,
retained secretions, secretions in the bronchi
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
EXPECTED OUTCOMES
The patient will
• Maintain patent airway.
• Have no adventitious breath sounds.
• Have a normal chest x-ray.
• Have an oxygen level in normal range.
• Breathe deeply and cough to remove secretions.
• Expectorate sputum.
• Demonstrate controlled coughing techniques.
• Have adequate ventilation.
• Demonstrate skill in conserving energy while attempting to clear
airway.
• State understanding of changes needed to diminish oxygen demands.
SUGGESTED NOC OUTCOMES
Aspiration Prevention; Respiratory Status: Airway Patency; Respiratory
Status: Ventilation
INTERVENTIONS AND RATIONALES
Determine: Assess respiratory status at least every 4 hr or according
to established standards. Obstruction in the airway leads to atelectasis,
pneumonia, or respiratory failure. Monitor arterial blood gases values
and hemoglobin levels to assess oxygenation and ventilatory
status. Report deviations from baseline levels; oxygen saturation
should be higher than 90%.
Monitor sputum, noting amount, odor, and consistency. Sputum
amount and consistency may indicate hydration status and effectiveness
of therapy. Foul-smelling sputum may indicate respiratory infection.
Perform: Turn patient every 2 hr; place the patient in lateral, sitting,
prone, and upright positions as much as possible for maximal aeration
of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest expansion
and ventilation.
Suction, as ordered, to stimulate cough and clear airways. Be alert
for progression of airway compromise. Perform postural drainage,
percussion, and vibration to facilitate secretion movement.
Provide adequate humidification to loosen secretions. Administer
expectorants, bronchodilators, and other drugs, as ordered, and monitor
effectiveness. Provide bronchodilator treatments before chest physiotherapy
to optimize results of the treatment. Administer oxygen, as
ordered, to promote oxygenation of cells throughout the body.
Inform: Teach patient an easily performed cough technique to clear
airway without fatigue.
Attend: Avoid placing patient in a supine position for extended periods
to prevent atelectasis.
When helping the patient cough and deep-breathe, use whatever
position best ensures cooperation and minimizes energy expenditure,
such as high Fowler’s position or sitting on side of bed. Such positions
promote chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (3–4 qt [3–4 L/day]) to ensure
optimal hydration and loosening of secretions, unless contraindicated.
Encourage sputum expectoration to remove pathogens and prevent
spread of infection. Provide tissues and paper bags for hygienic
disposal.
Manage: If conservative measures fail to maintain partial pressure of
arterial oxygen (PaO2) within an acceptable range, prepare for endotracheal
intubation, as ordered, to maintain artificial airway and
optimize PaO2 Level.
SUGGESTED NIC INTERVENTIONS
Airway Management; Aspiration Precautions; Cough Enhancement;
Oxygen Therapy; Respiratory Monitoring; Ventilation Assistance
Reference
Cigna, J. A., & Turner-Cigna, L. M. (2005, September). Rehabilitation for the
home care patient with COPD. Home Healthcare Nurse, 23(9), 578–584.

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