Nursing Diagnosis for COPD and Asthma | Ineffective Airway Clearance

Nursing diagnosis: ineffective airway clearance related to bronchospasm; increased production of secretions, retained secretions, thick, viscous secretions; decreased energy or fatigue.

Possibly evidenced by

Statement of difficulty breathing

Changes in depth and rate of respirations, use of accessory muscles

Abnormal breath sounds such as wheezes, rhonchi, crackles

Cough (persistent), with or without sputum production

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway with breath sounds clear or clearing.

Demonstrate behaviors to improve airway clearance.

Nursing care plan intervention with rationale:

1. Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi.

Rationale: Some degree of bronchospasm is present with obstructions in airway and may or 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. Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio.

Rationale: Tachypnea is usually present to some degree and may be pronounced on admission, during stress, or during concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.

3. Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 10 scale or American Thoracic Society’s Grade of Breathlessness Scale to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of

chronic dyspnea.

Rationale: Respiratory dysfunction is variable depending on the underlying process; for example, infection, allergic reaction, and the stage of chronicity in a client with established COPD. Note: Using a scale to rate dyspnea aids in quantifying and tracking changes in respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus.

4. Assist client to maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed.

Rationale: Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

5. Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation.

Rationale: Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode.

6. Encourage and assist with abdominal or pursed-lip breathing exercises.

Rationale: Provides client with some means to cope with and control dyspnea and reduce air-trapping.

7. Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort.

Rationale: Cough can be persistent but ineffective, especially if client is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.

8. Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals.

Rationale: Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric

distention and pressure on the diaphragm.

9. Administer medications, as indicated, for example: Beta-agonists, such as epinephrine (Adrenalin, AsthmaNefrin, Primatene, Sus-Phrine), albuterol (Proventil, Velmax, Ventolin, AccuNeb, Airet), formoterol (Foradil), levalbuterol (Xopenex); metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethine), and salmeterol (Serevent).

Rationale: Inhaled 2-adrenergic agonists are first-line therapies for rapid symptomatic improvement of bronchoconstriction. These medications relax smooth muscles and reduce local congestion, reducing airway spasm, wheezing, and mucus production. Medications may be oral, injected, or inhaled. Inhalation by metered-dose inhaler (MDI) with a spacer is

recommended, but medications may be nebulized in the event client has severe coughing or is too dyspneic to puff effectively.

10. Bronchodilators, such as anticholinergic agents: ipratropium (Atrovent).

Rationale: Inhaled anticholinergic agents are now considered the first-line drugs for clients with stable COPD because studies indicate they have a longer duration of action with less toxicity potential, whereas still providing the effective relief of the beta-agonists. Some of these medications are available in combinations; for example, albuterol and Atrovent are

available as Combivent.