ineffective Airway Clearance - Evaluation, Interventions, Documentation

Desired Outcomes/Evaluation
Criteria—Client Will:
• Maintain airway patency.
• Expectorate/clear secretions readily.
• Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
• Verbalize understanding of cause(s) and therapeutic management regimen.
• Demonstrate behaviors to improve or maintain clear airway.
• Identify potential complications and how to initiate appropriate preventive or corrective actions.

Actions/Interventions
NURSING PRIORITY NO. 1. To maintain adequate, patent airway:
• Position head midline with flexion appropriate for age/condition to open or maintain open airway in at-rest or compromised individual.
• Assist with appropriate testing (e.g., pulmonary function/ sleep studies) to identify causative/precipitating factors.
• Suction naso/tracheal/oral prn to clear airway when secretions are blocking airway.
• Elevate head of the bed/change position every 2 hours and prn to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments (pulmonary toilet).
• Monitor infant/child for feeding intolerance, abdominal distention, and emotional stressors that may compromise
airway.
• Insert oral airway as appropriate to maintain anatomic position of tongue and natural airway.
• Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
• Keep environment allergen free (e.g., dust, feather pillows, smoke) according to individual situation.

NURSING PRIORITY NO. 2. To mobilize secretions:
• Encourage deep-breathing and coughing exercises; splint chest/incision to maximize effort.
• Administer analgesics to improve cough when pain is inhibiting effort. (Caution: Overmedication can depress respirations and cough effort.)
• Give expectorants/bronchodilators as ordered.
• Increase fluid intake to at least 2000 mL/day within level of cardiac tolerance (may require IV) to help liquefy secretions. Monitor for signs/symptoms of congestive heart failure (crackles, edema, weight gain).
• Encourage/provide warm versus cold liquids as appropriate.
• Provide supplemental humidification, if needed (ultrasonic nebulizer, room humidifier).
• Perform/assist client with postural drainage and percussion as indicated if not contraindicated by condition, such as asthma.
• Assist with respiratory treatments (intermittent positivepressure breathing—IPPB, incentive spirometer).
• Support reduction/cessation of smoking to improve lung function.
• Discourage use of oil-based products around nose to prevent aspiration into lungs.

NURSING PRIORITY NO. 3. To assess changes, note complications:
• Auscultate breath sounds and assess air movement to ascertain status and note progress.
• Monitor vital signs, noting blood pressure/pulse changes.
• Observe for signs of respiratory distress (increased rate, restlessness/anxiety, use of accessory muscles for breathing).
• Evaluate changes in sleep pattern, noting insomnia or daytime somnolence.
• Document response to drug therapy and/or development of adverse side effects or interactions with antimicrobials,
steroids, expectorants, bronchodilators.
• Observe for signs/symptoms of infection (e.g., increased dyspnea with onset of fever, change in sputum color, amount, or character) to identify infectious process/promote timely intervention.
• Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy.
• Monitor/document serial chest x-rays/ABGs/pulse oximetry readings.
• Observe for improvement in symptoms.

NURSING PRIORITY NO. 4. To promote wellness (Teaching/
Discharge Considerations):
• Assess client’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures.
• Provide information about the necessity of raising and expectorating secretions versus swallowing them, to examine and report changes in color and amount.
• Demonstrate pursed-lip or diaphragmatic breathing techniques, if indicated.
• Review breathing exercises, effective cough, use of adjunct devices (e.g., IPPB or incentive spirometer) in preoperative teaching.

• Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. (Prevents/lessens fatigue.)
• Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction).
• Instruct in use of nocturnal positive pressure air flow for treatment of sleep apnea. (Refer to NDs disturbed Sleep
Pattern; 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.