NURSING DIAGNOSIS: Ineffective airway clearance

related to stasis of secretions associated with:
  1. decreased mobility;
  2. decreased effectiveness of cough resulting from diminished lung/chest wall expansion, depressant effect of certain medications (e.g. narcotic [opioid] analgesics, centrally acting muscle relaxants, sedatives), and possible tenacious secretions if fluid intake is inadequate.
Desired Outcome
The client will maintain clear, open airways as evidenced by:
  1. normal breath sounds
  2. normal rate and depth of respirations
  3. absence of dyspnea.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of ineffective airway clearance (e.g. abnormal breath sounds; rapid, shallow respirations; dyspnea; cough).
  2. Implement measures to promote effective airway clearance:
    1. perform actions to decrease pain if present (e.g. splint/protect painful area during movement, administer prescribed analgesics) in order to increase the client's willingness to move, cough, and deep breathe
    2. instruct and assist client to change position at least 2500 ml/day every 2 hours
    3. perform actions to promote the removal of secretions:
      1. instruct and assist client to deep breathe and cough or "huff" every 1 - 2 hours
      2. implement measures to thin tenacious secretions and reduce drying of the respiratory mucous membrane:
        1. maintain a fluid intake of at least unless contraindicated
        2. humidify inspired air as ordered
      3. assist with administration of mucolytics (e.g. acetylcysteine) and diluent or hydrating agents (e.g. water, saline) via nebulizer if ordered
      4. assist with or perform postural drainage therapy (PDT) if ordered
      5. perform suctioning if needed
    4. discourage smoking (the irritants in smoke increase mucus production, impair ciliary function, and can cause inflammation and damage to the bronchial walls)
    5. administer central nervous system depressants judiciously
    6. increase activity as allowed.
  3. Consult appropriate health care provider (e.g. physician, respiratory therapist) if:
    1. signs and symptoms of ineffective airway clearance persist
    2. signs and symptoms of impaired gas exchange (e.g. restlessness, irritability, confusion, significant decrease in oximetry results, decreased PaO2 and increased PaCO2 levels) are present.