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Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
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Airway Clearance, Ineffective
Sue Galanes, RN, MS, CCRN

NANDA: A state in which an individual is unable to clear secretions or obstructions from the respiratory tract to maintain airway patency

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (pneumonia, bronchitis, chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. The elderly who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production are at high risk.

Related Factors

Defining Characteristics

Expected Outcome

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.

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assess airway for patency.
Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.
(i) Auscultate lungs for presence of normal or adventitious breath sounds, as in the following:
(i) Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, position for breathing.
Abnormality indicates respiratory compromise.
(i) Assess changes in mental status.
Increasing lethargy, confusion, restlessness, and/or irritability can be early signs of cerebral hypoxia.
(i) Assess changes in vital signs and temperature.
Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/atelectasis.
(i) Assess cough for effectiveness and productivity.
Consider possible causes for ineffective cough: respiratory muscle fatigue, severe bronchospasm, thick tenacious secretions, and others.
(i) Note presence of sputum; assess quality, color, amount, odor, and consistency.
May be a result of infection, bronchitis, chronic smoking, and others. A sign of infection is discolored sputum (no longer clear or white); an odor may be present.
Send a sputum specimen for culture and sensitivity as appropriate.
Respiratory infections increase the work of breathing; antibiotic treatment is indicated.
(c) Monitor arterial blood gases (ABGs).
Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.
(i) Assess for pain.
Postoperative pain can result in shallow breathing and an ineffective cough.
(c) If patient is on mechanical ventilation, monitor for peak airway pressures and airway resistance.
Increases in these parameters signal accumulation of secretions/fluid and possibility for ineffective ventilation.
(i) Assess patient's knowledge of disease process.
Patient education will vary depending on the acute or chronic disease state as well as the patient's cognitive level.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Assist patient in performing coughing and breathing maneuvers.
To improve productivity of the cough.
(i) Instruct patient in the following:
(i) Use positioning
(if tolerated, head of bed at 45 degrees; sitting in chair, ambulation).
To facilitate clearing of secretions
These promote better lung expansion and improved air exchange.
(i) If bedridden, routinely check the patient's position so he or she does not slide down in bed.
This may cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.
(c) If cough is ineffective, use nasotracheal suctioning as needed
To remove sputum and mucous plugs.
(c) Institute appropriate isolation precautions for positive cultures (e.g., methicillin-resistant Staphylococcus aureus [MRSA], tuberculosis, and others).
(i) Use humidity (humidified O2 or humidifier at bedside).
To loosen secretions
(i) Encourage oral intake of fluids within the limits of cardiac reserve
To prevent drying of secretions.
(c) Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered, noting effectiveness and side effects.
(c) For patients with chronic problems with bronchoconstriction, instruct in use of meter dose inhaler (MDI) or nebulizer as prescribed.
(c) Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and home care/rehabilitation environments). Coordinate optimal time for postural drainage and percussion, that is, at least 1 hour after eating
To prevent aspiration.
(i) For patients with reduced energy, pace activities.
Maintain planned rest periods. Promote energy conservation techniques.
To prevent fatigue.
(c) For acute problem, assist with bronchoscopy
To obtain lavage samples for culture and sensitivity, and to remove mucous plugs.
(c) If secretions cannot be cleared, anticipate the need for an artificial airway (intubation). After intubation:
(c) For patients with complete airway obstruction, institute cardiopulmonary resuscitation (CPR) maneuvers.

Education/Continuity of Care

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Demonstrate and teach coughing, deep breathing, and splinting techniques
So patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.
(i) Instruct patient on indications for, frequency, and side effects of medications.
(i) Instruct patient how to use prescribed inhalers, as appropriate.
(i) In home setting, instruct caregivers regarding cough enhancement techniques and need for humidification.
(i) Instruct caregivers in suctioning techniques. Provide opportunity for return demonstration. Adapt technique for home setting.
(i) For patients with debilitating disease being cared for at home (CVA, neuromuscular impairment, and others), instruct caregiver in chest physiotherapy as appropriate.
This may also be useful for the patient with bronchiectasis, who is ambulatory but requires chest physiotherapy because of the volume of secretions and the inability to adequately clear them.
(i) Teach patient about environmental factors that can precipitate respiratory problems.
(i) Explain effects of smoking, including second-hand smoke.
(i) Refer patient and/or significant others to smoking-cessation group, as appropriate, and discuss potential use of smoking-cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to wean off the effects of nicotine.
(i) Instruct patient on warning signs of pending or recurring pulmonary problems.
(c) Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated.

NIC

Cough Enhancement; Airway Management; Airway Suctioning

See also:
  • Tracheostomy, Chapter 5, p. 533
  • Tuberculosis, Chapter 5, p. 539
  • Pneumonia, Chapter 5, p. 493


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