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NANDA Definition
NANDA Definition
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.
Defining Characteristics:
Related Factors:
Expected Outcomes
Related Factors:
• Airway Management
• Airway Suctioning
Ongoing Assessment
• Assess airway for patency.--Maintaining the airway is always the first priority,
especially in cases of trauma, acute neurological decompensation, or cardiac
arrest.
• Auscultate lungs for presence of normal or adventitious breath sounds, as in the
following:
o Decreased or absent breath sounds These may indicate presence of mucus
plug or other major airway obstruction.
o Wheezing These may indicate increasing airway resistance.
o Coarse sounds These may indicate presence of fluid along larger airways.
• Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea
on exertion, evidence of splinting, use of accessory muscles, and position for
breathing.--Abnormality indicates respiratory compromise.
• Assess changes in mental status.--Increasing lethargy, confusion, restlessness,
and/or irritability can be early signs of cerebral hypoxia.
• Assess changes in vital signs and temperature.--Tachycardia and hypertension
may be related to increased work of breathing. Fever may develop in response to
retained secretions/atelectasis.
• Assess cough for effectiveness and productivity.--Consider possible causes for
ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick
tenacious secretions).
• Note presence of sputum; assess quality, color, amount, odor, and consistency.
This may be a result of infection, bronchitis, chronic smoking, or other condition.
A sign of infection is discolored sputum (no longer clear or white); an odor may
be present.
Therapeutic Interventions
--Suctioning is indicated when patients are unable to remove secretions from the
airways by coughing because of weakness, thick mucus plugs, or excessive mucus
production.
Coordinate optimal time for postural drainage and percussion (i.e., at least 1 hour
after eating). This prevents aspiration.
• For patients with reduced energy, pace activities. Maintain planned rest periods.
Promote energy-conservation techniques.--Fatigue is a contributing factor to
ineffective coughing.
• For acute problem, assist with bronchoscopy.--This obtains lavage samples for
culture and sensitivity, and removes mucus plugs.
• If secretions cannot be cleared, anticipate the need for an artificial airway
(intubation). After intubation:
- Institute suctioning of airway as determined by presence of adventitious
sounds.
Education/Continuity of Care
Nursing Diagnosis:
Related Factors:
Risk Factors: