Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.
- Atrificial airway
- Excessive or thick secretions
- Inability to cough effectively
- Abnormal breath sounds (crackles, rhonchi, wheezes)
- Changes in respiratory rate or depth
- Chest wheezing
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Respiratory Status: Airway Patency
Suggested NIC Labels
- Cough Enhancement
- Airway Management
- Airway Suctioning
Patient’s secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
Nursing Interventions Nursing Care Plan Ineffective Airway Clearance
- Assess respiratory rate, depth, rythm, effort, and breath sounds.
- Position: HOB elevated.
- Promote optimum level of activity for best possible lung expansion:
- Suction per: Nasal, Oral, Tracheal