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Thursday, July 1, 2010

Nursing Diagnosis Ineffective Airway clearance

Nursing Diagnosis Ineffective Airway clearance Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Dyspnea, diminished breath sounds, orthopnea, adventitious breath sounds crackles, wheezes, cough, ineffective or absent sputum production, cyanosis, difficulty vocalizing, wide-eyed, changes in respiratory rate and rhythm, restlessness

Related Factors:
Environmental, Smoking, smoke inhalation, second-hand smoke, Obstructed Airway, Airway spasm, retained secretions, excessive mucus, presence of artificial airway, foreign body in airway, secretions in bronchi, exudates in alveoli, Physiological, Neuromuscular dysfunction, hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways

Nursing Outcomes
• Respiratory Status: Ventilation
• Respiratory Status: Airway Patency
• Respiratory Status: Gas Exchange
• Aspiration Control

• Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea
• Maintains a patent airway at all times
• Relates methods to enhance secretion removal
• Relates the significance of changes in sputum to include color, character, amount, and odor
• Identifies and avoids specific factors that inhibit effective airway clearance

Nursing Interventions
• Airway Management
• Airway Suctioning
• Cough Enhancement

  • Monitor respiratory, including patterns, rate, depth, and effort, Breath sounds.
  • Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours)
  • If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position
  • Teach client to deep breath and perform controlled coughing.
  • Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary.
  • Observe sputum, noting color, odor, and volume
  • Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side every 2 hours
  • Encourage increased fluid.
  • Administer oxygen as ordered.
  • Administer medications such as bronchodilators or inhaled steroids as ordered.
  • Provide Chest physical therapy: postural drainage, percussion, and vibration as ordered.
  • Refer for physical therapy or respiratory therapy for further treatment.
  • Monitor blood gas values and pulse oxygen saturation levels.
  • If the client has COPD, consider helping the client use the huff cough technique


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