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); those with excessive or abnormal mucus production
(e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation);
those with impaired cough function (e.g., neuromuscular diseases, such as muscular
dystrophy;
neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing
abnormalities
(e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial
burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly,
developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and
emotional stressors that may compromise airway) are all at risk for problems with
maintenance
of open airways.1,2
• Assess level of consciousness/cognition and ability to protect own airway. Information
essential
for identifying potential for airway problems, providing baseline level of care needed, and
influencing choice of interventions.
• Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some
degree and may be pronounced during respiratory stress. Respirations may be shallow. Some
degree of bronchospasm is present with obstruction in airways and may/may not be
manifested
in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with
expiratory wheezes (emphysema), or absent breath sounds (severe asthma).2
• Position head appropriate for age and condition/disorder. Repositioning head may, at times,
be all that is needed to open or maintain open airway in at-rest or compromised individual,
such as one with sleep apnea.
• Insert oral airway, using correct size for adult or child, when indicated. Have appropriate
emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction
apparatus) to restore or maintain an effective airway.3,4
• Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can
make it difficult to maintain effective airways, especially if client has impaired cough
function,
is very young or elderly, is developmentally delayed, has restrictive or obstructive lung
disease,
or is mechanically ventilated.5
• Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases
and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy,
muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical
ventilation
due to mechanisms affecting muscles of throat, chest, and lungs.5,6
• Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction
timing for child or adult to clear airway when secretions are blocking airways, client is
unable to clear airway by coughing, cough is ineffective, infant is unable to take oral
feedings
because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or
ABGs.2,5,7
ineffective AIRWAY CLEARANCE
52
• Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to
identify
causative/precipitating factors.
• Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
• Keep environment free of smoke, dust, and feather pillows according to individual situation.
Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute
episode.3
NURSING PRIORITY NO. 2 To mobilize secretions:
• Elevate head of the bed/change position, as needed. Elevation/upright position facilitates
respiratory function by use of gravity; however, the client in severe distress will seek position
of
comfort.3
• Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of
oilbased
products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs
risk for Aspiration, impaired Swallowing.)
• Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically)
and reinforce (postsurgically) breathing and coughing while splinting incision to maximize
cough effort, lung expansion, and drainage, and to reduce pain impairment.
• Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung
expansion and drainage of different lung segments.5
• Administer analgesics, as indicated. Analgesics may be needed to improve cough effort
when
pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations
and
cough effort.
• Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and
mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway
edema, and mobilize secretions.8
• Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in
acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate.
Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note:
Individuals with compromised cardiac function may develop symptoms of CHF (crackles,
edema, weight gain).4,5
• Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental
humidification,
helping to reduce viscosity of secretions.
• Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure
breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask,
mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough
techniques, etc.). Various therapies/modalities may be required to maintain adequate
airways,
improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern,
impaired Gas Exchange, impaired spontaneous Ventilation.)3,11
• Perform/assist client in learning airway clearance techniques, particularly when airway
congestion
is a chronic/long-term condition. Numerous techniques may be used, including (but not
limited
to) postural drainage and percussion (CPT), flutter devices, high-frequency chest
compression
with an inflatable vest, intrapulmonary percussive ventilation administered by a
percussinator, and
active cycle breathing (ACB), as indicated. Many of these techniques are the result of
research in
treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.9
NURSING PRIORITY NO. 3 To assess changes, note complications:
• Auscultate breath sounds, noting changes in air movement to ascertain current status/effects
of treatments to clear airways.
Cultural Collaborative Community/Home Care Diagnostic Studies
Pediatric/Geriatric/Lifespan Medications
ineffective AIRWAY CLEARANCE
• Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory
rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing
respiratory distress.
• Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies
baseline status, influences interventions, and monitors progress of condition and/or treatment
response.
• Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be
evidence
of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
• Document response to drug therapy and/or development of adverse reactions or side
effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological
therapy is used to prevent and control symptoms, reduce severity of exacerbations, and
improve health status. The choice of medications depends on availability of the medication
and the client’s decision making about medication regimen and response to any given
medication.10
• Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase
in sputum volume, change in color or character) to identify infectious process/promote timely
intervention.10
• Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify
appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of
symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and
antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial
antibiotic.10
NURSING PRIORITY NO. 4 To promote wellness (Teaching/Discharge Considerations):
• Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific
medications, and therapeutic procedures to determine educational needs.
• Provide information about the necessity of raising and expectorating secretions versus
swallowing them, to note changes in color and amount.
• Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and
intervention is required to prevent/treat infection.
• Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g.,
forced expiratory breathing [also called “huffing”] or respiratory muscle strength training,
chest percussion), if indicated.11
• Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g.,
IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery,
reduce risk of pneumonia.
• Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected
effects and information regarding possible side effects and interactions of respiratory drugs
with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up.
Client is often taking multiple medications that have similar side effects and potential for
interactions.
It is important to understand the difference between nuisance side effects (such as fast
heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or
uncontrolled cardiac arrhythmia).9
• Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance.
Prevents/diminishes fatigue associated with underlying condition or efforts to clear
airways.
• Urge reduction/cessation of smoking. Smoking is known to increase production of mucus
and
to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve
lung
function.10
Nursing Diagnoses in Alphabetical Order 53
ineffective AIRWAY CLEARANCE
54
• Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group,
weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular
Dystrophy Association).
• Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to
NDs Insomnia, Sleep Deprivation.)
DOCUMENTATION FOCUS
Assessment/Reassessment
• Related factors for individual client.
• Breath sounds, presence/character of secretions, use of accessory muscles for breathing.
• Character of cough/sputum.
Planning
• Plan of care and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.