Ineffective Airway Clearance | Nursing Care Plan for Lung Cancer

Nursing diagnosis: ineffective airway clearance related to increased amount or viscosity of secretions; restricted chest movement, pain; fatigue, weakness

Possibly evidenced by

Changes in rate and depth of respiration

Abnormal breath sounds

Ineffective cough

Dyspnea

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations.

Nursing intervention with rationale:

1. Auscultate chest for character of breath sounds and presence of secretions.

Rationale: Noisy respirations, rhonchi, and wheezes are indicative of retained secretions or airway obstruction.

2. Assist client with and provide instruction in effective deep breathing, coughing in upright position (sitting), and splinting of incision.

Rationale: Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse placing hands anteriorly and posteriorly over chest wall and by client, with pillows, as strength improves.

3. Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated.

Rationale: Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum suggests development of secondary problems—for example, dehydration, pulmonary edema, local hemorrhage, or infection—that require correction or treatment.

4. Suction if cough is weak or breath sounds not cleared by cough effort. Avoid deep endotracheal and nasotracheal suctioning in client who has had pneumonectomy if possible.

Rationale: “Routine” suctioning increases risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated following pneumonectomy to reduce the risk of rupture of the bronchial stump suture line. If suctioning is unavoidable, it should be done gently and only to induce effective coughing.

5. Encourage oral fluid intake, at least 2,500 mL/day, within cardiac tolerance.

Rationale: Adequate hydration aids in keeping secretions loose and enhances expectoration.

6. Assess for pain and discomfort and medicate on a routine basis and before breathing exercises.

Rationale: Encourages client to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency.

7. Provide and assist client with incentive spirometer and postural drainage and percussion, as indicated.

Rationale: Improves lung expansion and ventilation and facilitates removal of secretions. Note: Postural drainage may be contraindicated in some clients, and, in any event, must be performed cautiously to prevent respiratory embarrassment and incisional discomfort.

8. Use humidified oxygen and ultrasonic nebulizer. Provide additional fluids intravenously (IV), as indicated.

Rationale: Providing maximal hydration helps loosen and liquefy secretions to promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration.

9. Administer bronchodilators, expectorants, and analgesics, as indicated.

Rationale: Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce viscosity of secretions, facilitating removal. Alleviation of chest discomfort

promotes cooperation with breathing exercises and enhances effectiveness of respiratory therapies.