Many disease processes and acute situations can affect the airway.
Ineffective airway clearance is the inability to maintain a patent airway. Usually, protective mechanisms such as microscopic organisms or coughing keep the respiratory tract free of obstructions and secretions. However, if any of these mechanisms are impaired, there is a risk for a compromised airway.
- Inability to manage secretions
- Foreign bodies in the airway
- Artificial airway
- Muscle weakness
- Neuromuscular dysfunction
- Environmental factors such as smoke, pollution, and pollen
- Airway spasms
- Thick secretions from infectious process
Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)
- Verbalizes difficulty breathing
- Complains of feeling fatigued
- Reports a long history of tobacco use
- Reports having a cold for several weeks
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
- Adventitious breath sounds (i.e., crackles, rhonchi, wheezes)
- Altered respiratory rate, depth, and rhythm
- Large amount of secretions
- Past medical history(PMH) reveals a history of tobacco use
- Abnormal chest x-ray
- Positive sputum cultures
- Elevated white blood cell count
- Shortness of breath
- Absent cough
- The patient will maintain a clear airway
- The patient will have clear lung sounds
- The patient will demonstrate effective ways to remove secretions
- The patient will verbalize factors that contribute to hindering a clear airway.
- The patient will verbalize symptoms that require immediate medical attention
Nursing Assessment for Ineffective Airway Clearance
|Assess if the airway is patent. |
The highest priority is the patency of the airway.
|Perform a comprehensive respiratory assessment at least every four hours. Assess rate, rhythm, and depth of respiration. |
An initial respiratory assessment builds a baseline for further examinations. It allows for trending the improvements or worsening of the patient’s condition.
|Note the patient’s oxygen saturation. |
Oxygenation should be maintained at 90%. If the patient cannot keep a saturation above 90%, supplemental oxygen might be required.
|Assess for adventitious breath sounds. |
Diminished; No breath sounds.
Absent breath sounds might indicate an obstruction.
Might indicate a partial airway obstruction from narrowing of the airway due to, for example, bronchospasm.
Crackles (previously called rales).
Might indicate fluid or secretions in the airway.
May be caused by an obstruction of the trachea or bronchus.
Note the pitch, intensity, and duration during the assessment. These sounds can occur during inspiration and/or expiration.
|If the patient is not intubated or has a tracheostomy, note the sound of the voice. |
The presence of fluid or solid tissue can increase sounds. Increased vocal resonance indicates the presence of atelectasis, pleural effusion, pneumonia, or a solid mass.
|Assess the skin color and mucus membranes. |
Pallor and cyanosis may be indicators for deficient gas exchange and perfusion.
|Assess the nail beds and note if clubbing is present. |
Pale or blue nail beds may indicate a lack of perfusion. Clubbing of the fingernails means that the patient might have a long term history of compromised gas exchange and perfusion. Clubbing can be seen in conditions such as COPD or cystic fibrosis.
|Assess sputum for color, consistency, and amount. |
These characteristics provide information about the lung status of the patient. Yellow or greenish color sputum might be an indication of infection. Blood tinged, foamy sputum can be an indication of pulmonary edema.
|Note the patient’s work of breathing.|
Flaring of nostrils Use of accessory musclesTripod position Dyspnea
These signs are compensatory mechanisms that indicate a lack of adequate gas exchange. The patient’s endurance will decrease over time. The number of times the patient has to pause to complete a sentence shows the level of respiratory distress.
|Note the patient’s psychosocial condition. |
Anxiety over the feeling of not being able to breathe can often worsen the patient’s respiratory distress.
|Assess the level of consciousness. |
Lack of adequate oxygenation to the brain can cause restlessness and confusion. Prolonged cerebral hypoxia can cause lethargy and somnolence.
|Monitor blood pressure (BP), heart rate (HR), and temperature. |
Hypertension and tachycardia might be related to increased work of breathing, leading to increased respiratory distress and hypoxia. An elevated temperature can occur as a response to an infectious or inflammatory process.
|Obtain blood gases at least once per shift. Remember the normal arterial blood gas values. |
pH: 7.35 to 7.45
Pco2: 35 to 45 mm Hg
HCO3: 22 to 27 mEq/L
Po2: 80 to 100 mm Hg
O2 saturation: 96% to 100%
Blood gases reveal how well the patient oxygenates. Blood gases allow for close monitoring of patients’ treatment results so that adjustments can be made.
|Monitor RBC and WBC values. |
RBCs transport oxygen to the tissues. A decreased number of RBCs can lead to hypoxemia. An increased number of WBCs can be a manifestation of infection or inflammation.
|Send a sputum culture for analysis per order. |
Results provide specific information about the exact bacteria growth so that treatment can be targeted with the appropriate antibiotics.
|Assess the patient’s nutrition status. |
Long-term respiratory conditions such as COPD or cystic fibrosis can require a constant increased work of breathing. This leads to a high need for calories. However, patients may be too exhausted and fatigued to eat and, therefore, cannot maintain an adequate calorie intake.
|Assess the patient’s hydration status. Note |
BP and HR (BP might be low because of inadequate intravascular volume; HR may increase as a compensatory response)
Adequate hydration may help loosen thick secretion. Thin secretion may be easier to expectorate.
|Anticipate frequent orders of chest x-rays and/ or CT scans. |
Imaging results provide a more detailed picture of the disease process and allow for a more targeted treatment. Frequent images also provide a baseline and allow for comparison during the treatment process.
Nursing Interventions for Ineffective Airway Clearance
|Assist the patient to an optimal upright position. |
Sitting upright provides for an ideal body alignment for maximum lung expansion. Respiratory muscles, such as the diaphragm, have enough space to expand and contract.
|Administer supplemental oxygen as ordered. |
Adequate oxygenation facilitates gas exchange and perfusion.
|Instruct the patient on the correct use of the incentive spirometer and the use of the flutter valve as ordered. |
Instructions on using the incentive spirometer:
Assume an upright position seal lips around the mouthpiece
Inhale slowly to raise the indicator to the goal marking
Remove the mouthpiece and hold your breath for a few seconds before you exhale.
Repeat the process up to ten times per hour
The incentive spirometer helps open up the lungs and alveoli where gas exchange takes place. It can prevent lung complications such as developing pneumonia. The use of the flutter valve creates a vibrating effect of the upper chest, loosening hardened mucus and secretions.
|Encourage the client to cough and deep breathe. |
For example, instruct the patient to take a deep breath in and hold for several seconds. Cough two to three times during exhalation.
Induced coughing and deep breathing helps improve clearing secretions and increases oxygenation.
|Administer medications as ordered. For example, |
All these medications either treat inflammatory or infectious processes or help improve breathing by reducing airway resistance.
|Collaborate with respiratory therapists. |
The patient might benefit from specialized treatment plans such as chest physiotherapy or scheduled nebulizer treatments.
|Encourage adequate fluid intake, if not contraindicated. |
Increased fluid intake may help thinning secretions; however, some patients do not tolerate high fluid intake due to cardiac compromise, such as heart failure.
|For acute conditions, anticipate interventions such as bronchoscopy or intubation. |
Bronchoscopy is an exploratory procedure that allows the removal of obstructions and obtainment of samples for testing. If the patient’s oxygenation cannot be maintained with noninvasive measures, intubation is indicated.
For the Critical Care Patient: Intubation or Tracheostomy
|If the patient is unable to move, elevate the head of the bed at least 30 degrees at all times. |
Keeping the chest in an upright position helps with lung expansion and reduces aspiration of secretions.
|Consider the use of a rotoprone bed.|
Rotoprone beds allow for patients to be placed in the prone position. Frequent position changes reduce pooling of secretions and therefore reduces the risk of developing infectious processes.
|If a rotoprone bed is not an option, turn and reposition the patient at least every two hours. |
Changing positions frequently for the bed-bound patient may reduce respiratory complications and improve the ability to come off the ventilator.
|Suction the patient if indicated. Suppose a tracheostomy is in place, deep suction the patient to remove secretions. Deep suctioning is a sterile procedure. |
During intubation or having a tracheostomy, the patient cannot clear his or her secretions. Suctioning, as needed, will keep the airway clear.
Patient Teaching and Continuity of Care for Ineffective Airway Clearance
|Educate about the disease process. |
Information about the disease and its possible outcomes might improve compliance with the treatment plan.
|Teach about coughing and deep breathing techniques. |
These breathing exercises increase oxygenation, help reduce secretions, and help reduce dyspneic episodes.
|Educate the patient about the use of medications. |
Regular and correct usage of prescribed medications promotes safety and the best outcome possible.
|Explain the effects of contributing factors to lung problems. |
Teaching about smoking cessation or other factors affecting ventilation is vital for the patient’s recovery. Avoiding allergens or other irritants may reduce bronchospasms and other respiratory problems.
|Teach family and caregivers how to suction the patient if needed. |
Being familiar with suctioning techniques promotes patient safety.
|Recommend the family and caregiver to attend a basic life support course. |
In case of emergency, the family will be able to provide necessary life support measures before first responders arrive.
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