INEFFECTIVE AIRWAY CLEARANCE
Definition:
Inability to clear secretions or obstructions from the respiratory
tract to maintain a clear airway
Related Factors:
Environmental
Smoking; second-hand smoke; smoke inhalation
Obstructed airway
Retained secretions; secretions in the bronchi; exudate in the
alveoli; excessive mucus; airway spasm; foreign body in
airway; presence of artificial airway
Physiological
Chronic obstructive pulmonary disease (COPD); asthma; allergic
airways; hyperplasia of the bronchial walls; neuromuscular dysfunction;
infection
Defining Characteristics:
Subjective
Dyspnea
Objective
Diminished or adventitious breath sounds (rales, crackles,
rhonchi, wheezes) Cough, ineffective or absent; sputum Changes in respiratory
rate and rhythm Difficulty vocalizing Wide-eyed; restlessness Orthopnea Cyanosis
Expected outcomes
The patient will
- · Maintain patent airway.
- · Have no adventitious breath sounds.
- · Have a normal chest x-ray.
- · Have an oxygen level in normal range.
- · Breathe deeply and cough to remove secretions.
- · Expectorate sputum.
- · Demonstrate controlled coughing techniques.
- · Have adequate ventilation.
- Demonstrate skill in conserving energy while attempting to clear airway.
- · State understanding of changes needed to diminish oxygen demands.
Interventions and Rationales:
Determine:
Assess respiratory status at least every 4 hr or according to
established standards. Obstruction in the airway leads to
atelectasis, pneumonia, or respiratory failure. Monitor arterial blood
gases values and hemoglobin levels to assess oxygenation and
ventilatory status. Report deviations from baseline levels; oxygen
saturation should be higher than 90%.
Monitor sputum, noting amount, odor, and consistency. Sputum
amount and consistency may indicate hydration status and effectiveness of
therapy. Foul-smelling sputum may indicate respiratory infection.
Perform:
Turn patient every 2 hr; place the patient in lateral, sitting,
prone, and upright positions as much as possible for maximal aeration
of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest
expansion and ventilation.
Suction, as ordered, to stimulate cough and clear airways. Be
alert for progression of airway compromise. Perform postural drainage,
percussion, and vibration to facilitate secretion movement.
Provide adequate humidification to loosen secretions. Administer
expectorants, bronchodilators, and other drugs, as ordered, and monitor
effectiveness. Provide bronchodilator treatments before chest physiotherapy to
optimize results of the treatment. Administer oxygen, as ordered, to promote
oxygenation of cells throughout the body.
Inform:
Teach patient an easily performed cough technique to clear
airway without fatigue.
Attend:
Avoid placing patient in a supine position for extended
periods to prevent atelectasis.
When helping the patient cough and deep-breathe, use whatever
position best ensures cooperation and minimizes energy expenditure, such as
high Fowler’s position or sitting on side of bed. Such positions promote
chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (3–4 qt [3–4 L/day]) to
ensure optimal hydration and loosening of secretions, unless contraindicated. Encourage
sputum expectoration to remove pathogens and prevent spread
of infection. Provide tissues and paper bags for hygienic disposal.
Manage:
If conservative measures fail to maintain partial pressure of
arterial oxygen (PaO2) within an acceptable range, prepare for endotracheal
intubation, as ordered, to maintain artificial airway and optimize PaO2
Level
Reference:
Cigna, J. A., & Turner-Cigna, L. M. (2005, September).
Rehabilitation for the home care patient with COPD. Home Healthcare Nurse,
23(9), 578–584.
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