Risk for Ineffective Airway Clearance | NCP Thyroidectomy

Nursing diagnosis: risk for ineffective Airway Clearance

Risk factors may include
Tracheal obstruction; swelling, bleeding, laryngeal spasms.
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Maintain patent airway, with aspiration prevented.

Nursing intervention with rationale:
1. Monitor respiratory rate, depth, and work of breathing.
Rationale: Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage.

2. Auscultate breath sounds, noting presence of rhonchi.
Rationale: Rhonchi may indicate airway obstruction and accumulation of copious thick secretions.

3. Assess for dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice.
Rationale: Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention.

4. Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period.
Rationale: Enhances breathing and reduces likelihood of tension on surgical wound.

5. Assist with repositioning, deep breathing exercises, and coughing, as indicated.
Rationale: Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions.

7. Ascertain that suction equipment is functioning and available. Suction mouth and trachea, as indicated, noting color and characteristics of sputum.
Rationale: Edema and pain may impair client’s ability to clear own airway.

8. Check dressing frequently, especially posterior portion.
Rationale: If bleeding occurs, anterior dressing may appear dry because blood pools dependently. Note: Highest risk of bleeding is first postoperative 2 hours, but risk continues up to 24 hours.

9. Investigate reports of difficulty swallowing and drooling of oral secretions.
Rationale: May indicate edema and sequestered bleeding in tissues surrounding operative site.

10. Keep tracheostomy tray at bedside.
Rationale: Compromised airway may create a life-threatening situation requiring emergency procedure.

risk for ineffective Breathing Pattern/Airway Clearance | Nursing Care Plan for Disc Surgery

Nursing diagnosis: risk for ineffective Breathing Pattern/Airway Clearance

Risk factors may include
Tracheal and bronchial obstruction or edema
Decreased lung expansion or pain

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain a normal, effective respiratory pattern free of cyanosis and other signs of hypoxia, with arterial blood gases (ABGs) within acceptable range.

Nursing intervention with rationale
1. Inspect for edema of face and neck (cervical laminectomy), especially first 24 to 48 hours after surgery.
Rationale: Tracheal edema and compression or nerve injury can compromise respiratory function.

2. Listen for hoarseness. Encourage voice rest.
Rationale: Hoarseness may indicate laryngeal nerve injury or edema of surgical area, which can negatively affect cough and ability to clear airway.

3. Auscultate breath sounds. Note presence of wheezes or rhonchi.
Rationale: Abnormal breath sounds suggest accumulation of secretions or need to engage in more aggressive therapeutic actions to clear airway.

4. Assist with coughing, turning, and deep breathing. Encourage client’s use of incentive spirometry or other devices used to aid deep breathing.
Rationale: These maneuvers facilitate movement of secretions and clearing of lungs. They also reduce the risk of such respiratory complications as pneumonia, pulmonary embolus, and others.

5. Administer supplemental oxygen, if indicated.
Rationale: Supplemental oxygen may be necessary for periods of respiratory distress or evidence of hypoxia.

6. Monitor and graph ABGs or pulse oximetry.
Rationale: Monitors adequacy of breathing and oxygen therapy.

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.

Ineffective Airway Clearance | Nursing Care Plan for Ventilatory Assistance

Nursing diagnosis: Ineffective airway clearance related to foreign body (artificial airway) in the trachea; inability to cough or ineffective cough

Possibly evidenced by

Changes in rate or depth of respiration

Cyanosis

Abnormal breath sounds

Anxiety and restlessness

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway with breath sounds clear.

Be free of aspiration.

Caregiver Will

Identify potential complications and initiate appropriate actions.

Nursing intervention with rationale:

1. Assess airway patency.

Rationale: Obstruction may be caused by accumulation of secretions, mucous plugs, hemorrhage, bronchospasm, and problems with the position of tracheostomy or ET tube.

2. Evaluate chest movement and auscultate for bilateral breath sounds.

Rationale: Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement and unobstructed airflow. Lower airway obstruction, such as pneumonia

or atelectasis, produces changes in breath sounds, such as rhonchi and wheezing.

3. Monitor ET tube placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or

repositioning tube.

Rationale: The ET tube may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting client at risk for a tension pneumothorax.

4. Note excessive coughing, increased dyspnea (using a 0 to 10 scale), high-pressure alarm sounding on ventilator, visible secretions in endotracheal or tracheostomy tube,

and increased rhonchi.

Rationale: The intubated client often has an ineffective cough reflex, or client may have neuromuscular or neurosensory impairment, altering ability to cough. Client is usually dependent on suctioning to remove secretions. Note: Research supports use of a dyspnea rating scale (like those used to measure pain) to more accurately quantify and measure

changes in dyspnea as experienced by client.

5. Suction as needed when client is coughing or experiencing respiratory distress, limiting duration of suction to 15 seconds or less. Choose appropriate suction catheter. Hyperventilate before and after each catheter pass, using 100% oxygen if appropriate, using vent rather than Ambu bag, which has an increased risk of barotrauma. Suction continuously or intermittently during withdrawal.

Rationale: Suctioning should not be routine, and duration should be limited to reduce hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal diameter of the ET or tracheostomy tube for prevention of hypoxia. Hyperoxygenation with ventilator sigh on 100% oxygen may be desired to reduce atelectasis and to reduce accidental hypoxia. Note: Instilling normal saline (NS) is no longer recommended (although it persists in practice) because research reveals that the fluid pools at the distal end of the ET or tracheal tube, impairing oxygenation and increasing bronchospasm and the risk of infection.

6. Use inline catheter suction when available.

Rationale: Reduces risk of infection for healthcare workers and helps maintain oxygen saturation and PEEP when used.

7. Instruct client in coughing techniques during suctioning, such as splinting, timing of breathing, and “quad cough,” as indicated.

Rationale: Enhances effectiveness of cough effort and secretion clearing.

8. Reposition or turn periodically.

Rationale: Promotes drainage of secretions and ventilation to all lung segments, reducing risk of atelectasis.

9. Encourage the client to drink fluids and provide fluids within individual capability.

Rationale: Helps liquefy secretions, enhancing expectoration.

10. Provide chest physiotherapy as indicated, such as postural drainage and percussion.

Rationale: Promotes ventilation of all lung segments and aids drainage of secretions.

Ineffective Airway Clearance | Nursing Care Plan for Radical Neck Surgery

Nursing diagnosisi: ineffective airway clearance related to partial or total removal of the glottis, altering ability to breathe, cough, and swallow; temporary or permanent change to neck breathing—dependent on patent stoma; edema formation—surgical manipulation and lymphatic accumulation; copious and thick secretions

Possibly evidenced by

Dyspnea and difficulty breathing

Changes in rate and depth of respiration; use of accessory respiratory muscles

Abnormal breath sounds

Cyanosis

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Airway Patency

Maintain patent airway with breath sounds clear or clearing.

Clear secretions and be free of aspiration.

Nursing intervention with rationale:

1. Monitor respiratory rate and depth; note ease of breathing. Auscultate breath sounds. Investigate restlessness, dyspnea, and development of cyanosis.

Rationale: Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction (even partial) can lead to ineffective breathing patterns and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest.

2. Elevate head of bed 30 to 45 degrees.

Rationale: Facilitates drainage of secretions, work of breathing, and lung expansion. Note: Increase elevation when oral intake is provided.

3. Encourage swallowing, if client is able.

Rationale: Prevents pooling of oral secretions, reducing risk of aspiration. Note: Swallowing is impaired when the epiglottis is removed and/or significant postoperative edema and pain are present.

4. Encourage effective coughing and deep breathing.

Rationale: Mobilizes secretions to clear airway and helps prevent respiratory complications.

5. Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions.

Rationale: Prevents secretions from obstructing airway, especially when swallowing ability is impaired and client cannot blow nose. Changes in character of secretions may indicate developing

problems, such as dehydration and infection, and need for further evaluation and treatment.

6. Demonstrate and encourage client to begin self-suction procedures as soon as possible. Educate client in “clean” techniques.

Rationale: Assists client to exercise some control in postoperative care and prevention of complications. Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone.

7. Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated.

Rationale: As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels.

8. Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings.

Rationale: Small amount of oozing may be present; however, continued bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction

and suffocation.

9. Change tube and inner cannula, as indicated. Instruct client in cleaning procedures.

Rationale: Prevents accumulation of secretions and thick mucous plugs from obstructing airway. Note: This is a common cause of respiratory distress and arrest in later postoperative period.

10. Provide supplemental humidification, such as compressed air or oxygen mist collar and increased fluid intake.

Rationale: Normal physiological (nasal passages) means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma.

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.

Nursing Diagnosis for Pneumonia | Ineffective Airway Clearance

Nursing diagnosis: ineffective airway clearance related to tracheal bronchial inflammation, edema formation, increased sputum production; pleuritic pain; decreased energy, fatigue.

Possibly evidenced by
Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles
Dyspnea, cyanosis
Cough, effective or ineffective; with or without sputum production

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Airway Patency
Identify and demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing and absence of dyspnea and cyanosis.

Nursing care plan intervention with rationale:
1. Assess rate and depth of respirations and chest movement. Monitor for signs of respiratory failure; for example, cyanosis and severe tachypnea.
Rationale: Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall or fluid in lung. When pneumonia is severe, the client may require endotracheal intubation and mechanical ventilation to keep airways clear.

2. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds, such as crackles and wheezes.
Rationale: Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and expiration in response to fluid accumulation, thick secretions, and airway spasm or obstruction.

3. Elevate head of bed; change position frequently.
Rationale: Keeping the head elevated lowers diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear.

4. Assist client with frequent deep-breathing exercises. Demonstrate and help client, as needed; learn to perform activity, such as splinting chest and effective coughing while in upright position.
Rationale: Deep breathing facilitates maximum expansion of the lungs and smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. Note: Cough associated with pneumonias may last days, weeks, or even months.

5. Suction, as indicated; for example, oxygen desaturation related to airway secretions.
Rationale: Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough or decreased level of consciousness.

6. Force fluids to at least 2,500 mL per day, unless contraindicated, as in HF. Offer warm, rather than cold, fluids.
Rationale: Fluids, especially warm liquids, aid in mobilization and expectoration of secretions.

7. Assist with and monitor effects of nebulizer treatments and other respiratory physiotherapy, such as incentive spirometer, intermittent positive-pressure breathing (IPPB), percussion, and postural drainage. Perform treatments between meals and limit fluids when appropriate.
Rationale: Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates or destruction. Coordination of treatments, schedules, and oral intake reduces likelihood of vomiting with coughing and expectorations.

8. Administer medications, as indicated, for example mucolytics, expectorants, bronchodilators, and analgesics.
Rationale: Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort and depress respirations.

9. Provide supplemental fluids such as IV, humidified oxygen, and room humidification.
Rationale: Fluids are required to replace losses, including insensible, and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.

10. Monitor serial chest x-rays, ABGs, and pulse oximetry readings.
Rationale: Follows progress and effects of disease process and therapeutic regimen, and facilitates necessary alterations in therapy.

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.