Nursing Care Plan for Ineffective Airway Clearance

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1. Pathophysiology
2. Nursing Assessment
3. Nursing Interventions
4. NCLEX Question

Ineffective Airway Clearance Pathophysiology

Ineffective airway clearance refers to the inability of the client to effectively clear secretions or obstructions from the airway, leading to compromised oxygenation and ventilation. It can be caused by a variety of factors, including inflammation, mucus production, and airway obstruction.

Causes of Ineffective Airway Clearance

• Chronic obstructive pulmonary disease (COPD)
• Pneumonia
• Asthma
• Cystic fibrosis
• Bronchitis
• Emphysema
• Smoking
• Allergic reactions
• Aspiration
• Neuromuscular disorders
• Trauma

Symptoms of Ineffective Airway Clearance

• Dyspnea (shortness of breath)
• Wheezing
• Cough
• Increased respiratory rate
• Use of accessory muscles for breathing
• Chest tightness or pain
• Inability to clear secretions
• Cyanosis (bluish discoloration of the skin or mucous membranes due to lack of oxygen)

Subjective Data (Client Reports)

• Shortness of breath
• Chest tightness or pain
• Difficulty breathing

Objective Data

• Increased respiratory rate
• Use of accessory muscles for breathing
• Wheezing
• Cyanosis
• Inability to clear secretions

Risk Factors

• Advanced age
• Chronic respiratory disease
• Smoking
• Exposure to air pollution
• Immobility
• Poor nutrition
• Dehydration

Ineffective Airway Clearance Nursing Assessment

• Cardiac, respiratory, neurologic, and sensory functions.
• Oxygen saturation levels.
• Lung sounds and note any abnormalities.
• Cough and ability to clear secretions.
• Level of consciousness and mental status.
• Skin color and temperature.

Cardiac Function

• Irregular heart rate and rhythm.
• Elevated blood pressure.

Respiratory function

• Irregular respiratory rate, lung sounds, and pattern.
• Impaired oxygen saturation levels.
• Cough and inability to clear secretions.

Neurologic function

• Altered level of consciousness.
• Impaired mental status.
• Inability to follow commands.

Sensory function

• Impaired vision and hearing.
• Inability to communicate.

Labs (Evaluate and Report)

• Arterial blood gas analysis
• Complete blood count (CBC)
• Electrolyte levels

Ineffective Airway Clearance Nursing Interventions

• Administer supplemental oxygen and bronchodilators as prescribed.
• Encourage deep breathing and coughing exercises.
• Position the client upright to promote lung expansion.
• Assist the client with positioning to promote effective breathing.
• Monitor the client’s oxygen saturation levels and lung sounds

Goals and Outcomes

• Maintain oxygen saturation levels above 90%.
• Effectively clear secretions.
• Increased ease of breathing
• Improved lung sounds.
• Perform deep breathing and coughing exercises independently.

Ineffective Airway Clearance NCLEX Question

Which recommendation is appropriate for the nurse to provide when a client reports sleep disturbances due to ineffective airway clearance related to chronic bronchitis? Select all that apply.

1. Drink at least 2 to 3 liters of oral fluids daily.
2. Use a cool mist humidifier at bedtime.
3. Practice breathing slowly through puckered lips throughout the night.
4. Take guaifenesin 400 mg orally every 4 hours.
5. Use chest physiotherapy as needed.
6. Use a tripod breathing position throughout the night.

Answers: A, B, D, & E

Drinking plenty of fluids can help thin the thick mucus that is clogging the airway due to the diagnosis of chronic bronchitis allowing for expectoration.

A cool mist humidifier increases the humidity of the air in the room which thins the secretions associated with chronic bronchitis thereby allowing for easier expectoration.

Guaifenesin is an expectorant that helps loosen secretions and increases the ability to cough up the mucus.

Chest physiotherapy is an airway clearance technique to drain the lungs. The technique includes percussion, vibration, deep breathing, and coughing.