Ineffective Airway Clearance

Airway spasm

Allergic airway

Asthma

Chronic obstructive pulmonary disease

Congenital heart disease

Critical illness

Exudate in the alveoli

General anesthesia

Hyperplasia of the bronchial walls

Neuromuscular diseases

Respiratory tract infection

AUTHOR'S NOTE

The nursing focus for the above problem is on preventing aspiration through proper positioning and good oral hygiene, not on teaching effective coughing. Thus, the nurse should restate the diagnosis as Risk for Aspiration related to decreased cough and gag reflexes secondary to anesthesia or utilize Ineffective Airway Clearance. Foreign bodies in the upper respiratory system do not represent a nursing diagnosis but rather a medical emergency.

CLINICAL ALERT

A cough ("the guardian of the lungs") is accomplished by closure of the glottis and the explosive expulsion of air from the lungs by the work of the abdominal and chest muscles. Although most coughing serves a beneficial purpose, the following may be signs of a medical problem requiring medical intervention (Grossman & Porth, 2014).

Level 1 Fundamental Focused Assessment

See Risk for Ineffective Respiratory Function.

NOC

Aspiration Control, Respiratory Status

The individual will not experience aspiration, as evidenced by the following indicators:

Demonstrates effective coughing.

Demonstrates increased air exchange.

Level 1 Fundamental Focused Interventions (all settings)

NIC

Cough Enhancement, Airway Suctioning, Positioning, Energy Management

The nursing interventions for the diagnosis Ineffective Airway Clearance represent interventions for any individual with this nursing diagnosis, regardless of the related factors.

Assess for Causative or Contributing Factors

Refer to Related Factors.

Assess and Evaluate

Sputum (color, volume, odor)

Respiratory status before and after coughing exercises (peripheral capillary oxygen saturation [SpO₂], breath sounds, rate, rhythm)

R:These assessments can detect abnormal sputum (green, yellow, bloody) and retained secretions).

CLINICAL ALERT

The most significant risk factor for hospital-acquired pneumonia (HAP) is mechanical ventilation. Ventilator-associated pneumonia is the second most common nosocomial infection and the leading cause of death from nosocomial infections in critically ill individuals with the highest rates in immunocompromised, surgical, and elderly individuals. Mouth care is critical in prevention (Timsit, Esaied, Neuville, Bouadma, & Mourvllier, 2017; Klompas, 2021). Research has noted an increased incidence of HAP when the gastric pH is increased with the use of H₂ blockers, antacids, or PPIs (Klompas, 2021).

If the individual is on a ventilator, it is recommended to (Klompas, 2021):

Elevate the head of the bed to 30 to 45°.

Minimize sedation.

Drain subglottic secretions in ventilated individuals.

Maintain prescribed endotracheal tube airway cuff pressure (20 to 30 cm H₂O).

Ensure That Oral Care Is Provided Every 4 Hours, as Indicated

If the individual is on a ventilator every 2 hours or 12 times in 24 hours:

Brush teeth at 8

and 8

Cleanse the mouth with tooth sponges 10 times per day.

If prescribed, question the use of chlorhexidine in mouth care.

Refer to Risk for Impaired Oral Mucous Membrane Integrity for additional interventions.

R:Oral care with a toothbrush reduces plaque and bacteria, which can increase infection in lungs. Optimal oral care can improve appetite and promote positive interactions by reducing odor. An increase in mortality with chlorhexidine use was detected in a single meta-analysis of 11 trials evaluating 2618 ICU patients when compared with placebo (Price & MacLennan, 2014; Klompas, 2021).

Reduce or Eliminate Barriers to Airway Clearance

Inability to Maintain Proper Position

Assist with positioning frequently; monitor for risk for aspiration (see Risk for Aspiration).

Ineffective Cough

Instruct on the proper method of controlled coughing.

Breathe deeply and slowly while sitting up as high as possible.

R:Sitting upright shifts the abdominal organs away from the lungs, enabling greater expansion.

Use diaphragmatic breathing.

R:Diaphragmatic breathing reduces the respiratory rate and increases alveolar ventilation.

Hold the breath for 3 to 5 seconds, then slowly exhale as much of this breath as possible through the mouth (lower rib cage and abdomen should sink down).

Take a second breath; hold, slowly exhale, and cough forcefully from the chest (not from the back of the mouth or throat), using 2 short, forceful coughs.

Increase fluid intake if not contraindicated.

R:Deep breathing dilates the airways, stimulates surfactant production, and expands the lung tissue surface, thus improving respiratory gas exchange. Coughing loosens secretions and forces them into the bronchus to be expectorated or suctioned.

In some individuals, "huffing" breathing may be more effective and is less painful.

Sit comfortably and breathe out slowly and completely.

Take a slow, deep breath in, using diaphragmatic-breathing (also called belly-breathing).

Hold your breath from 1 to 3 seconds.

Tighten your upper abdominal muscles and "huff" the air out quickly and forcefully.

As you huff, keep your mouth open and your chin slightly up.

It sometimes helps to say the word "huff" softly as you force the air out.

Take 2 or 3 slow deep breaths in and out.

Repeat steps 2 through 5.

Do this 3 to 4 times.

R:Learning this simple technique will help the individual cough gently without causing stress to their lungs. For a visual instructive document, download The Active Cycle of Breathing Techniques at https://www.acprc.org.uk/Data/Publication_Downloads/GL-05ACBT.pdf.

Pain or Fear of Pain Related to Surgery or Trauma

Assess present analgesic regimen.

Administer pain medications as needed.

Coordinate analgesic doses with coughing sessions (e.g., give doses 30 to 60 minutes before coughing sessions).

Assess medication's effectiveness: Is the individual too lethargic? Is he or she still in pain?

Note the time when the individual seems to have the best pain relief with optimal level of alertness and physical performance. This is the time for active breathing and coughing exercises.

Explain the importance of coughing after pain relief. Reassure that suture lines are secure and demonstrate that splinting by hand or pillow will minimize pain of movement. Continually reinforce the rationale for coughing. ("I will be back to help you cough when the pain medicine is working.")

R:Pain or fear of pain can inhibit participation in coughing and breathing exercises. Adequate pain relief is essential.

For viscous (thick) secretions:

Maintain adequate hydration (increase fluid intake to 2 to 3 qt a day if not contraindicated by decreased cardiac output or renal insufficiency).

R:Secretions must be sufficiently liquid to enable expulsion.

Fatigue, Weakness, and Drowsiness

Vigorously coach and encourage coughing, using positive reinforcement. ("You worked hard; I know it's not easy, but it is important.")

Be sure the coughing session occurs at the peak comfort period after analgesics, but not at peak level of sleepiness.

Allow for rest after coughing and before meals.

Provide Health Teaching and Referrals, as Indicated

Teach the individual and family:

Hydration requirements, mouth care

Effective coughing techniques

Signs of infection (change in sputum color, fever)

Refer to home health nursing if indicated

R:Instructions to continue effective coughing at home are needed to prevent retention of secretions and infection.

section name header

NANDA-I Definition ⬇

NANDA-I Defining Characteristics ⬆ ⬇

NANDA-I Related Factors ⬆ ⬇

NANDA-I At Risk Population ⬆ ⬇

NANDA-I Associated Conditions ⬆ ⬇

Goals ⬆