Ineffective Airway Clearance Nursing Care Plan

Actual Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Ineffective Airway Clearance"
Patient
Problem
( Actual )
Nursing diagnosis \ Ineffective airway clearance related to (contributing factor
according to the patient’s condition)
Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives
Short term


In 2 days, the patient will…
 Demonstrate increased air exchange.
 Classify methods to enhance secretion removal.
 Recognize the significance of changes in sputum to include color,
character, amount, and odor.
 Identify and avoid specific factors that inhibit effective airway clearance.
Long term

In 2 days, the patient will…
 Patient will maintain clear, open airways as evidence by normal breath
sounds, normal rate and depth of respirations, and ability to effectively
cough up secretions after treatments and deep breaths.
Nursing intervention

Assessment

 Assess airway for patency.
- Rationale: Maintaining patent airway is always the first priority, especially
in cases like trauma, acute neurological decompensation, or cardiac arrest.

 Auscultate lungs for presence of normal or adventitious breath sounds, as
in the following:
- Rationale: Abnormal breath sounds can be heard as fluid and mucus
accumulate. This may indicate ineffective airway clearance.

 Decreased or absent breath sounds
- Rationale: These may indicate presence of a mucous plug or other major
obstruction.

2.  Wheezing
- Rationale: This may indicate partial airway obstruction or resistance.

 Coarse crackle
- Rationale: This may indicate presence of secretions along larger airways.

 Note for changes in mental status.
- Rationale: Increasing lethargy, confusion, restlessness, and/or irritability
can be initial signs of cerebral hypoxia. Lethargy and somnolence are late
signs.

 Note for changes in HR, BP, and temperature.
- Rationale: Increased work of breathing can lead to tachycardia and
hypertension. Retained secretions or atelectasis may be a sign of an
existing infection or inflammatory process manifested by a fever or
increased temperature.

 Note cough for efficacy and productivity.
- Rationale: Coughing is a mechanism for clearing secretions. An
ineffective cough compromises airway clearance and prevents mucus
from being expelled. Respiratory muscle fatigue, severe bronchospasm, or
thick and tenacious secretions are possible causes of ineffective cough.

 Note presence of sputum; evaluate its quality, color, amount, odor, and
consistency.
Rationale: Unusual appearance of secretions may be a result of infection,
bronchitis, chronic smoking, or other condition. A discolored sputum is a sign
of infection; an odor may be present. Dehydration may be present if patient
has labored breathing with thick, tenacious secretions that increase airway
resistance.

 Submit a sputum specimen for culture and sensitivity testing, as
appropriate.
- Rationale: Labored breathing may be a sign of respiratory infection that
needs an appropriate treatment of antibiotics.

 Use pulse oximetry to monitor oxygen saturation; assess arterial blood
gases (ABGs)
- Rationale: Pulse oximetry is used to detect changes in oxygenation.
Oxygen saturation should be maintained at 90% or greater. Alteration in
ABGS may result in increased pulmonary secretions and respiratory
fatigue.

3. Interventions

 Position the patient upright if tolerated. Regularly check the patient’s
position to prevent sliding down in bed.
- Rationale: Upright position limits abdominal contents from pushing
upward and inhibiting lung expansion. This position promotes better lung
expansion and improved air exchange.

 Perform nasotracheal suctioning as necessary, especially if cough is
ineffective.
- Rationale: Suction is needed when patients are unable to cough out
secretions properly due to weakness, thick mucus plugs, or excessive or
tenacious mucus production.

 Maintain humidified oxygen as prescribed.
- Rationale: Increasing humidity of inspired air will reduce thickness of
secretions and aid their removal.

 Encourage patient to increase fluid intake to 3 liters per day within the
limits of cardiac reserve and renal function.
- Rationale: Fluids help minimize mucosal drying and maximize ciliary
action to move secretions.

 Give medications as prescribed, such as antibiotics, mucolytic agents,
bronchodilators, expectorants, noting effectiveness and side effects.
- Rationale: A variety of medications are prepared to manage specific
problems. Most promote clearance of airway secretions and may reduce
airway resistance.

 Coordinate with a respiratory therapist for chest physiotherapy and
nebulizer management as indicated.
- Rationale: Chest physiotherapy includes the techniques of postural
drainage and chest percussion to mobilize secretions from smaller airways
that cannot be eliminated by means of coughing or suctioning.

 Provide oral care every 4 hours.
- Rationale: Oral care freshens the mouth after respiratory secretions have
been expectorated.

4. Health Teaching


 Teach the patient the proper ways of coughing and breathing. (e.g., take
a deep breath, hold for 2 seconds, and cough two or three times in
succession).
- Rationale: The most convenient way to remove most secretions is
coughing. Therefore, it is necessary to assist the patient during this
activity. Deep breathing, on the other hand, promotes oxygenation before
controlled coughing.

 Educate the patient in the following:
 Optimal positioning (sitting position).
 Use of pillow or hand splints when coughing.
 Use of abdominal muscles for more forceful cough.
 Use of quad and huff techniques.
 Use of incentive spirometry.
 Importance of ambulation and frequent position changes.
- Rationale: The proper sitting position and splinting of the abdomen
promote effective coughing by increasing abdominal pressure and upward
diaphragmatic movement. Controlled coughing methods help mobilize
secretions from smaller airways to larger airways because the coughing is
done at varying times. Ambulation promotes lung expansion, mobilizes
secretions, and lessens atelectasis.

 Instruct patient about the need for adequate fluid intake even after
hospital discharge.
- Rationale: Hydration facilitates easy elimination of secretions.


 Educate caregivers in suctioning techniques. Provide opportunity for
return demonstration. Modify techniques for home setting.
- Rationale: This promotes safe and effective removal of secretions from
the airway.


 Consider verbalization of feelings.
- Rationale: Recognize reality of situation. Anxiety adds to oxygen
demand, and hypoxemia potentiates respiratory distress or cardiac
symptoms, which in turn increases anxiety.

 Explain further the effects of smoking, including secondhand smoke.
- Rationale: Chemical irritants and allergens can increase mucus
production and bronchospasm.

5. Evaluation

Achieved ( ) Partially achieved ( ) Not achieved ( )

Evidence by:





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