What causes ineffective airway clearance in nursing?
Nursing Assessment for Ineffective Airway Clearance. Coughing is a mechanism for clearing secretions. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough.
What causes ineffective airway clearance in COPD?
Ineffective Airway Clearance. Cause Analysis: In COPD, smoke or other environmental pollutants irritate the airways, resulting in hypersecretion of mucus and inflammation. This constant irritation causes the mucus-secreting glands and goblet cells to increase in number, ciliary function is reduced, and more mucus is produced.
Who is at high risk for ineffective airway clearance?
High-risk for ineffective airway clearance are the aged individuals who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production.
What are the symptoms of ineffective airway clearance?
Ineffective Airway Clearance. Problem Identified: Ineffective airway clearance. Nursing Diagnoses: Ineffective Airway Clearance r/t bronchospasm, increased secretion production and decreased energy. Cause Analysis: In COPD, smoke or other environmental pollutants irritate the airways, resulting in hypersecretion of mucus and inflammation.
What are the related factors for ineffective breathing pattern?
The related factors of Ineffective Breathing Pattern were the related factors fatigue, age and group of diseases. Conclusion: fatigue, age and patients with a group of diseases were related factors of Ineffective Breathing Pattern in this study.
What causes ineffective airway clearance in asthma?
Dehydration can contribute in viscous secretions and may result to decrease airway clearance. Monitor oxygen saturation using pulse oximetry. Oxygen saturation of less than 90% indicates problems with oxygenation.
How does COPD cause ineffective airway clearance?
Ineffective Airway Clearance Common to many pulmonary diseases is bronchospasm that reduces the caliber of the small bronchi and may cause difficulty in breathing, stasis of secretions, and infection.
What are the nursing interventions for ineffective airway clearance?
Nursing Care Plan for Ineffective Airway Clearance 3Nursing Interventions for Ineffective Airway ClearanceRationalePrepare suction machine in the patient's bedside.The patient may not be able to cough out the foreign body and build up of secretions. Suctioning will prevent the worsening of obstruction.5 more rows
How do you promote airway clearance?
The techniques that you can usually do yourself include:Deep coughing. This is a deep, controlled cough. ... Huff coughing. ... Self drainage or autogenic drainage (AD). ... Active cycle of breathing therapy (ACBT). ... Physical exercise.
What are 2 priority problems for the patient with a COPD exacerbation?
Complications. There are two major life-threatening complications of COPD: respiratory insufficiency and failure. Respiratory failure.
Expected Outcomes
Patient will maintain a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions
Nursing Assessment for Ineffective Airway Clearance
1.
Nursing Interventions for Ineffective Airway Clearance
1. Position to decrease secretions. Maintain an elevated head of bed as tolerated to help prevent secretions from accumulating. Sliding down in the bed or a slumped posture prevents proper lung expansion.
References and Sources
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
What is ineffective airway clearance?
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.
What does increased vocal resonance mean?
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.
How to help dyspneic patients?
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.
What does a yellow sputum mean?
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.
How to help bronchospasms?
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.
How often should you perform a respiratory assessment?
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.
Why is my temperature elevated?
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.
Management of Asthmatic Attacks
A medication regimen is usually instituted during the exacerbations of the disease. The type of medication given to patients depends on the symptoms being presented, the priority of care, and the individual’s age. These are also done relative to the results of other tests performed on the patient.
Asthma Nursing Care Plan
Patients with asthma suffer mainly from respiratory symptoms, and the nurse should address these symptoms as soon as they are identified. Nursing diagnoses for patients with asthma center mostly on airway clearance, breathing patterns, and gas exchange but also include other issues involving endurance, anxiety, and even nutritional status.
Ineffective airway clearance
Ineffective airway clearance related to (indicate one or more of the following related factors: airway spasm, production of thick tenacious sputum, retention of sputum, etc.) secondary to the diagnosis of asthma as evidenced by (include assessment findings specific to which particular symptoms the patient is manifesting such as:
INTERVENTIONS
Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time; note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow ( hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency).
RATIONALES
Reveals rate and type of respirations (baselines or deviations) that are related to age and size of the infant/child, changes that indicate obstruction and consolidation of airways and lungs resulting in a decrease in lung surface for gas diffusion, extreme changes in depth are abnormal, head bobbing indicates dyspnea in the infant and fatigue causing neck flexion, grunting indicates respiratory distress..
Prevents drying of oral mucous membranes
Prevents excessive energy expenditure and need for additional oxygen consumption, which changes respiratory status while still providing moderate activity and diversion of play.
Recommend swimming as a form of physical exercise
Teach parents to use bulb syringe to remove mucus from infant's nose, demonstrate and instruct in oropharyogeal suctioning if appropriate; allow return demonstration.
INTERVENTIONS
Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time; note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow ( hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency).
RATIONALES
Reveals rate and type of respirations (baselines or deviations) that are related to age and size of the infant/child, changes that indicate obstruction and consolidation of airways and lungs resulting in a decrease in lung surface for gas diffusion, extreme changes in depth are abnormal, head bobbing indicates dyspnea in the infant and fatigue causing neck flexion, grunting indicates respiratory distress..
Prevents drying of oral mucous membranes
Prevents excessive energy expenditure and need for additional oxygen consumption, which changes respiratory status while still providing moderate activity and diversion of play.
Recommend swimming as a form of physical exercise
Teach parents to use bulb syringe to remove mucus from infant's nose, demonstrate and instruct in oropharyogeal suctioning if appropriate; allow return demonstration.
