Nursing Diagnosis: Ineffective Airway Clearance
NANDA Definition : Inability 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 (e.g., pneumonia, bronchitis, and 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. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.
Defining Characteristics: Abnormal breath sounds (crackles, rhonchi, wheezes)
* Changes in respiratory rate or depth
* Cough
* Hypoxemia/cyanosis
* Dyspnea
* Chest wheezing
* Fever
* Tachycardia
Related Factors: Decreased energy and fatigue
* Ineffective cough
* Tracheobronchial infection
* Tracheobronchial obstruction (including foreign body aspiration)
* Copious tracheobronchial secretions
* Perceptual/cognitive impairment
* Impaired respiratory muscle function
* Trauma
NOC Outcomes (Nursing Outcomes Classification)
* Respiratory Status: Airway Patency
NIC Interventions (Nursing Interventions Classification)
* Cough Enhancement
* Airway Management
* Airway Suctioning
Expected Outcomes 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.