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Ineffective Airway Clearance - Nursing Outcome and Interventions

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Ineffective Airway Clearance

related to:
  • Infection, neuromuscular dysfunction, bronchial wall hyperplasia, airway allergies, asthma, trauma
  • Airway obstruction: airway spasms, restrained secretions, excessive mucus, the presence of artificial airways, bronchial secretions, the presence of exudates in the alveoli, the presence of foreign objects in the airway.
Subjective Data:
  • Dyspnea

Objective Data:
  • Decreased breath sounds
  • Orthopnea
  • Cyanosis
  • Abnormalities of breath sounds (rales, wheezing)
  • Difficulty speaking
  • Coughing, ineffective or absent
  • Sputum production
  • Nervous
  • Changes in the frequency and rhythm of the breath
Nursing Outcomes :
  • Respiratory status: Ventilation
  • Respiratory status: Airway patency
  • Aspiration Control
After nursing action for ………… .. the patient shows the effectiveness of the airway as evidenced by the results criteria:
  • Demonstrate effective coughing and clean breath sounds, no cyanosis and dyspneu (capable of removing sputum, breathing easily, no pursed lips)
  • Showing a patent airway (the client does not feel suffocated, breathing rhythm and respiratory frequency in the normal range, no abnormal breath sounds)
  • Able to identify and prevent factors that cause.
  • O2 saturation is within normal limits
  • Thoracic photos within normal limits
Interventions :
  • Ensure oral / tracheal suctioning needs.
  • Give O2 …… l / min, method ………
  • Encourage the patient to rest and breathe deeply
  • Position the patient to maximize ventilation
  • Perform chest physiotherapy if necessary
  • Remove the secretion by coughing or suctioning
  • Auscultation of breath sounds, note the presence of additional sounds
  • Monitor hemodynamic status
  • Set intake for liquids to optimize balance.
  • Monitor respiration and O2 status
  • Maintain adequate hydration to thin secretions
  • Explain to patients and families about the use of equipment: O2, Suction, Inhalation.



Reference :

NANDA International, Inc. Nursing Diagnoses Definitions and Classification
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