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

Physiologic

  • Chronic obstructive pulmonary disease (COPD); asthma
  • Allergic [Reactive] airways; hyperplasia of the bronchial walls
  • Neuromuscular dysfunction [Neurological disorders]
  • [Immobility]
  • Infection


SAMPLE CLINICAL APPLICATIONS: Chronic obstructive pulmonary disease (COPD), pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic fibrosis, neuromuscular diseases, inhalation injuries.


DESIRED OUTCOMES/EVALUATION CRITERIA


Sample NOC linkages:

  • Respiratory Status: Airway Patency: Extent to which the tracheobronchial passages remain open
  • Aspiration Control: Personal actions to prevent the passage of fluid and solid particles into the lung
  • Cognitive Ability: Ability to execute complex mental processes

ACTIONS/INTERVENTIONS

Sample NIC linkages:

  • Airway Management: Facilitation of patency of air passages
  • Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
  • Cough Enhancement: Promotion of deep inhalation by the patient with subsequentgeneration of high intrathoracic pressures and compression of underlying lung parenchyma for the forceful expulsion of air.


NURSING PRIORITY NO. 1. To maintain adequate, patent airway:

● Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post heart-lung transplantation);

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