Ineffective Airway Clearance | Nursing Care Plan for Tuberculosis

Nursing diagnosis: ineffective airway clearance related to thick, viscous, or bloody secretions; fatigue, poor cough effort; tracheal or pharyngeal edema

Possibly evidenced by

Abnormal respiratory rate, rhythm, depth

Abnormal breath sounds—rhonchi, wheezes, stridor

Dyspnea

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway.

Expectorate secretions without assistance.

Demonstrate behaviors to improve or maintain airway clearance.

Participate in treatment regimen, within the level of ability and situation.

Identify potential complications and initiate appropriate actions.

Nursing intervention with rationale:

1. Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles.

Rationale: Diminished breath sounds may reflect atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory

muscles and increased work of breathing.

2. Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of hemoptysis.

Rationale: Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Bloodtinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention.

3. Place client in semi- or high-Fowler’s position. Assist client with coughing and deep-breathing exercises.

Rationale: Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement of secretions into larger

airways for expectoration.

4. Clear secretions from mouth and trachea; suction as necessary.

Rationale: Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions.

5. Maintain fluid intake of at least 2,500 mL/day unless contraindicated.

Rationale: High fluid intake helps thin secretions, making them easier to expectorate.

6. Humidify inspired oxygen.

Rationale: Prevents drying of mucous membranes and helps thin secretions.

7. Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst)

Rationale: Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance.

8. Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur)

Rationale: Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.

9. Corticosteroids (prednisone)

Rationale: May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening.

10. Be prepared for and assist with emergency intubation.

Rationale: Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.