Perform nasotracheal suctioning as necessary, especially if cough is ineffective. A change in the usual respiration may mean respiratory compromise. Gil Wayne graduated in 2008 with a bachelor of science in nursing. Nursing assessment and intervention are the keys to maintaining airway patency in the patient with an artificial airway in place. Using well-lubricated catheters reduces irritation and prevents trauma to mucous membranes. Use sterile saline solution for the period of suctioning. Life-threatening situations may arise when cough proves ineffective as a result of muscle weakness or altered mucociliary function. Ineffective airway clearance related to excess tenacious mucus; Therapeutic Intervention / Medical Management Treatment for lung problems includes: Antibiotics to prevent and treat lung and sinus infections. Auscultate lungs for presence of normal or adventitious breath sounds, as in the following: Abnormal breath sounds can be heard as fluid and mucus accumulate. Consider the need of humidifiers in home care setting. NCP Ineffective Airway Clearance - Free download as Word Doc (.doc), PDF File (.pdf), Text File (.txt) or read online for free. Ineffective airway clearance. Perform cardiopulmonary resuscitation (CPR) maneuvers for patients with complete airway obstruction. Bronchoscopy acquires lavage samples for culture and sensitivity, and eliminates mucous plugs. Frequency of suctioning should be based on patient’s present condition, not on preset routine, such as every 2 hours. Continuous low-pitched, rattling lung sounds that often resemble snoring. Provide postural drainage, percussion, and vibration as ordered. Ineffective airway clearance R/T upper airway obstruction by tongue and soft tissues, inability to clear respiratory secretions as evidenced by unclear lung sounds, unequal lung expansion, noisy respiration, presence of stridor, cyanosis, or pallor. Stop suctioning and provide supplemental oxygen if the patient experiences bradycardia, an increase in ventricular ectopy, and/or significant desaturation. Chest, 153(4), 986-993. This procedure can also stimulate a cough. These may indicate presence of a mucous plug or other major obstruction. Scribd is the world's largest social reading and publishing site. Oral care freshens the mouth after respiratory secretions have been expectorated. A variety of medications are prepared to manage specific problems. However, coughing may not always be easy to everyone especially to those patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular weakness. Ineffective airway clearance occurs when an artificial airway is used because normal mucociliary transport mechanisms are bypassed and impaired. Otherwise, scroll down to view this completed care plan. A discolored sputum is a sign of infection; an odor may be present. Pain can result in shallow breathing and an ineffective cough. Lethargy and somnolence are late signs. His goal is to expand his horizon in nursing-related topics. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs. ASSESSMENT DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION Cyanosis Dyspnea Inspiratory and expiratory wheezing RR: 36/min and labored Ineffective airway clearance related to bronchoconstriction Bronchospasm, which occurs in many pulmonary diseases, reduced the caliber of the small bronchi and may cause dyspnea, static secretions, and â¦ Note for changes in HR, BP, and temperature. Nurseslabs â NCLEX Practice Questions, Nursing Study Guides, and Care Plans, Ineffective Airway Clearance Nursing Care Plan, Nursing Assessment for Ineffective Airway Clearance, Nursing Interventions for Ineffective Airway Clearance, 35+ Best Gifts for Nurses: Ideas and Tips, Arterial Blood Gas Interpretation for NCLEX (40 Questions), Arterial Blood Gas Analysis Made Easy with Tic-Tac-Toe Method, Select All That Apply NCLEX Practice Questions and Tips (100 Items), IV Flow Rate Calculation NCLEX Reviewer & Practice Questions (60 Items), EKG Interpretation & Heart Arrhythmias Cheat Sheet. Increasing humidity of inspired air will reduce thickness of secretions and aid their removal. Ineffective Airway Care Plan. ineffective airway clearance would be a nonproductive congestive cough or inability to clear sputum. Breathing comes naturally and effortlessly to everyone. Assess breath sounds by auscultation, Presence of artificial airway 7. This may indicate partial airway obstruction or resistance. Patient is a 41 year old, Give medications as prescribed, such as antibiotics, mucolytic agents, bronchodilators, expectorants, noting effectiveness and side effects. The Nursing Clinics of North America, 22(1), 167-178. 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). Pulse oximetry is used to detect changes in oxygenation. Mechanisms that exist in the lower bronchioles and alveoli to maintain the patency of the airway include the mucociliary system, macrophages, and the lymphatics. Labored breathing may be a sign of respiratory infection that needs an appropriate treatment of antibiotics. Once intubated: Readiness for an emergency helps prevent further complications. NCP COPD - Ineffective Airway Clearance Chronic obstructive pulmonary disease (COPD) also known as emphysema and chronic bronchitis is a very serious disease. Shekleton, M. E., & Nield, M. (1987). Assess hydration status: skin turgor, mucous membranes, tongue. Decreased energy and fatigue 4. Note presence of sputum; evaluate its quality, color, amount, odor, and consistency. Usually, protective mechanisms such as microscopic organisms or coughing keep the respiratory tract free of obstructions and secretions. Retained secretions or atelectasis may be a sign of an existing infection or inflammatory process manifested by a fever or increased temperature. The following are the therapeutic nursing interventions for ineffective airway clearance: Here are some recommended materials and sources for Ineffective Airway Clearance: Nurseslabs.comÂ is an education and nursing lifestyle website geared towards helping student nurses and registered nurses with knowledge for the progression and empowerment of their nursing careers. Nursing Care Plan For Ineffective Airway Clearance. The patient will verbalize symptoms that require immediate medical attention. When a problem concerning the airway happens, coughing takes place, which is the main mechanism for clearing it. Ineffective airway clearance is the inability to maintain a patent airway. INEFFECTIVE AIRWAY CLEARANCE. Instruct the patient to take several deep breaths before and after nasotracheal suctioning procedure and use supplemental oxygen, as appropriate. But there are some who are incapable of keeping their airways clear and their lungs healthy. An increase in respiratory rate and rhythm may be a compensatory response to airway obstruction. There are many reasons for this. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. Refer for home health aide services for assist with ADLs. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. Pace activities especially for patients with reduced energy. Commentary on da Silva VM, de Oliviera Lopes MV, de Araujo TL, Ciol MA, de Carvahlo EC (2009) Clinical indicators of ineffective airway clearance in children with congenital heart disease. Ineffective airway clearance related to inflamed lung tissue, irritation to the respiratory tract and difficulty to expectorate respiratory secretion due to presence of artificial airway; tracheostomy as manifestated by thick yellow tenacious sputum, presence of adventitious breath sounds, decrease SaO2, elevated respiratory rate and increased body temperature. This facilitates liquefaction of secretions. Drug interactions with prescribed medications and contraindications need to be evaluated (e.g., ma huang contains ephedrine, which should not be used by patients with increased BP, heart disease, prostate problems, and diabetes). Know if patient considers use of herbal treatment (e.g., echinacea for URTI, goldenseal for pneumonia, ma huang for bronchospasm). Copious and tenacious tracheobronchial secretions 3. Nursing school is difficult. Unusual appearance of secretions may be a result of infection, bronchitis, chronic smoking, or other condition. Ineffective Breathing Pattern. 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