Nursing Diagnosis: Ineffective Airway clearance Application of NANDA, NOC, NIC

Nursing Diagnosis: Ineffective Airway clearance
Betty J. Ackley

NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics: Dyspnea; diminished breath sounds; orthopnea; adventitious breath sounds (crackles, wheezes); cough, ineffective or absent; sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in respiratory rate and rhythm; restlessness

Related Factors:

Environmental

Smoking; smoke inhalation; second-hand smoke

Obstructed Airway

Airway spasm; retained secretions; excessive mucus; presence of artificial airway; foreign body in airway; secretions in bronchi; exudate in alveoli

Physiological

Neuromuscular dysfunction; hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways

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NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Respiratory Status: Ventilation

·         Respiratory Status: Airway Patency

·         Respiratory Status: Gas Exchange

·         Aspiration Control

Client Outcomes

·         Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea

·         Maintains a patent airway at all times

·         Relates methods to enhance secretion removal

·         Relates the significance of changes in sputum to include color, character, amount, and odor

·         Identifies and avoids specific factors that inhibit effective airway clearance

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Airway Management

·         Airway Suctioning

·         Cough Enhancement

Nursing Interventions and Rationales

·         Auscultate breath sounds q __ h(rs). Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction.

·         Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase.

·         Monitor blood gas values and pulse oxygen saturation levels as available. Normal blood gas values are a PO2 of 80 to 100 mm Hg and a PCO2 of 35 to 45 mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from ventilation-perfusion mismatches secondary to respiratory secretions.

·         Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours). An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position (Torres, Serra-Battles, Ros, 1992; Drakulovic et al, 1999).

·         If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position (with a 10- to 15-degree elevation and "good lung down") for 60 to 90 minutes. This method is contraindicated for a client with a pulmonary abscess or hemorrhage or with interstitial emphysema. Gravity and hydrostatic pressure allow the dependent lung to become better ventilated and perfused, which increases oxygenation (Yeaw, 1992; Smith-Sims, 2001).

·         Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

·         If the client has COPD, consider helping the client use the "huff cough." The client does a series of coughs while saying the word "huff." This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the centra airways (Lewis, Heitkemper, Dirksen, 1999).

·         Encourage client to use incentive spirometer. The incentive spirometer is an effective tool that can help prevent atelectasis and retention of bronchial secretions (Peruzzi, Smith, 1995).

·         Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Do not do nasotracheal suctioning. It is preferable for the client to cough up secretions. In the debilitated client, gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions; nasotracheal suctioning is dangerous because the nurse is unable to hyperoxygenate before, during, and after to maintain adequate oxygenation (Peruzzi, Smith, 1995).

·         Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

·         When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:

o    Hyperoxygenate before, between, and after endotracheal suction sessions. Nursing research has demonstrated that the client should be hyperoxygenated during suctioning (Winslow, 1993a).

o    Use a closed, in-line suction system. The closed, in-line suction system is associated with a decrease in nosocomial pneumonia (Deppe et al, 1990; Johnson et al, 1994; Mathews, Mathews, 2000), reduced suction-induced hypoxemia, and fewer physiological disturbances (including decreased development of dysrhythmia) and often saves money (Carroll, 1998).

o    Avoid saline instillation during suctioning. Saline instillation before suctioning has an adverse effect on oxygen saturation (Ackerman, Mick, 1998; Winslow, 1993b; Raymond, 1995).

·         Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.

·         Provide oral care every 4 hours. Oral care freshens the mouth after respiratory secretions have been expectorated. Research is promising on the use of chlorhexidine oral rinses after oral care to reduce bacteria, and possibly reduce the incidence of nosocomial pneumonia (Kollef, 1999).

·         Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours. Body movement helps mobilize secretions. The supine position and immobility have been shown to predispose postoperative clients to pneumonia (Brooks-Brunn, 1995). See interventions for Impaired gas exchange for further information on positioning a respiratory client.

·         Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions (Carroll, 1994). Some clients cannot tolerate increased fluids because of underlying disease.

·         Administer oxygen as ordered. Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions.

·         Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, inflamed pharynx with inhaled steroids. Bronchodilators decrease airway resistance secondary to bronchoconstriction.

·         Provide postural drainage, percussion, and vibration as ordered. Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if client has underlying conditions such as cardiac disease or increased intracranial pressure (Peruzzi, Smith, 1995).

·         Refer for physical therapy or respiratory therapy for further treatment.

Geriatric

·         Encourage ambulation as tolerated without causing exhaustion. Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia (Hoyt, 1992; Tempkin, Tempkin, Goodman, 1997).

·         Actively encourage the elderly to deep breathe and cough. Cough reflexes are blunted and coughing is decreased in the elderly (Sparrow, Weiss, 1988).

·         Ensure adequate hydration within cardiac and renal reserves. The elderly are prone to dehydration and therefore more viscous secretions because they frequently use diuretics or laxatives and forget to drink adequate amounts of water (Hoyt, 1992).

Home Care Interventions

·         Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, stressful family relationships).

·         Limit client exposure to persons with upper respiratory infections.

·         Provide/teach percussion and postural drainage per physician orders. Teach adaptive breathing techniques. Adaptive breathing, percussion, and postural drainage loosen secretions and allow more effective oxygenation.

·         Determine client compliance with medical regimen.

·         Teach client when and how to use inhalant or nebulizer treatments at home.

·         Teach client/family importance of maintaining regimen and having prn drugs easily accessible at all times. Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.

·         Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life threatening.

·         Refer for home health aide services for assist with ADLs. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

·         Assess family for role changes and coping skills. Refer to medical social services as necessary. Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity.

·         Provide family with support for care of a client with a chronic or terminal illness. Severe compromise to respiratory function creates fear in clients and caregivers. Fear inhibits effective coping.

Client/Family Teaching

·         Teach importance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. All health care clinicians should be aggressive in helping smokers quit (AHCPR Guidelines, 1996).

·         Teach client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open. This device has been shown to effectively decrease mucous viscosity and elasticity (App et al, 1998), increase amount of sputum expectorated (Langenderfer, 1998; Bellone et al, 2000), and increase peak expiratory flow rate (Burioka et al, 1998).

·         Teach client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids following precautions to decrease side effects (Owen, 1999).

·         Teach client how to deep breathe and cough effectively. Teach how to use the ELTGOL method-an airway clearance method that uses lateral posture and diferent lung volumes to control expiratory flow of air to avoid airway compression. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. The ELTGOL method was shown to be more effective in secretion removal in chronic bronchitis than postural drainage (Bellone et al, 2000).

·         Teach client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to second-hand smoke.

·         Educate client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor. With this knowledge the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

·         Teach client/family need to take antibiotics until prescription has run out. Taking the entire course of antibiotics helps to eradicate bacterial infection, which decreases lingering, chronic infection.