Nursing Diagnosis: Ineffective Airway Clearance
Definition of Ineffective Airway Clearance
- Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Defining Characteristics of 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 of Ineffective Airway Clearance
- 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 | Nursing Care Plan for Ineffective Airway Clearance
Nursing Diagnosis for Ineffective Airway Clearance| Assessment Focus; Expected Outcomes; Suggested NOC Outcomes
Assessment Focus of Ineffective Airway Clearance (Refer To Comprehensive Assessment Parameters.)
- Activity/exercise
- Cardiac function
- Respiratory function
Expected Outcomes | Nursing Diagnosis for Ineffective Airway Clearance
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 | Nursing Diagnosis for Ineffective Airway Clearance
Aspiration Prevention; Respiratory Status: Airway Patency; Respiratory Status: Ventilation
Nursing Interventions of Ineffective Airway Clearance | Nursing Care Plan for Ineffective Airway Clearance
Nursing Diagnosis for Ineffective Airway Clearance | Nursing Interventions of Ineffective Airway Clearance and Rationales; Suggested NIC Interventions
Nursing Interventions of Ineffective Airway Clearance and Rationales
- 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 ventilator 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.
- 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.
- Teach patient an easily performed cough technique to clear airway without fatigue.
- 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.
- 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 | Nursing Diagnosis for Ineffective Airway Clearance
Airway Management; Aspiration Precautions; Cough Enhancement; Oxygen Therapy; Respiratory Monitoring; Ventilation Assistance
This is a sample of Nursing Care Plan for Ineffective Airway Clearance