Nursing Diagnosis
Nursing Diagnosis:
Ineffective Airway
Clearance
Possible Etiologies:
(Related to)
• Bronchospasm
• Increased production
of secretions; retained
secretions; thick,
viscous secretions
• Decreased energy/
fatigue
Defining characteristics:
(Evidenced by)
• Statement of difficulty
in breathing
• Feeling of chest
constriction
• Changes in depth/ rate
of respiration;
tachypnea
• Tachycardia
• Use of accessory
muscles or marked
respiratory effort
• Abnormal breath
sound, inspiratory and
expiratory wheezing
• Cough (persistent),
without sputum
production
• Prolonged expiration
Objectives Nursing Interventions
Goals/ Objectives: Nursing Actions
Short term goal:
Client will demonstrate
signs of patent airway
and adequate oxygen
exchange within 3 days.
Long term goal:
Client will demonstrate
behaviours to improve
or maintain airway
clearance and identify
potential complications
and initiate appropriate
actions.
Rationale Evaluation
Outcome
1. Some degree in Criteria:
1. Assess respiratory status bronchospasm is present Client will
every hour during acute with obstruction in
verbalize
phase: lung sounds, airway and may be
respiratory rate and depth, manifested with reduction or
presence and severity of wheezing or absent absence in
wheezing, breathing pattern, breath sounds in severe difficulty in
use of accessory muscles. asthma. Tachypnea is breathing and
2. Assist patient to assume to usually present to some feeling of chest
comfortable position, i.e. degree and respiratory constriction,
elevate head of bed, have dysfunction is variable
respiration and
client lean on over bed table depending on underlying
or sit on the edge of bed. process such as allergic cardiac rate
3. Keep environmental reaction. within normal
pollution to a minimum 2. Elevation of head of the range, absence or
according to individual bed facilitates respiratory reduction of
situation. function by use of inspiratory and
4. Encourage and assist gravity, however client in expiratory
abdominal and pursed – lip distress may seek
wheezing, and
breathing exercises. position that most eases
5. Increase fluid intake to breathing. ability to resume
3000ml/ day within cardiac 3. Precipitators of allergic to activities.
tolerance. type of respiratory Client will be
6. Provide warm liquids and reactions that can trigger able to identify
recommend intake of fluids or exacerbate onset of and avoid
between meals, instead of acute episode. potential
during meals. 4. Provides some means to
7. Administer medications as cope with or control allergens or
indicated. dyspnea and reduce air stimuli that would
8. Monitor side effects of trapping. trigger asthma
bronchodilator (tremors/ 5. Hydration helps thin attack and be able
tachycardia). secretions, facilitating to handle
9. Provide supplemental expectoration and using symptoms if
humidification, e.g., warm liquids may
recurrence comes,
neutralizer in respiratory decrease bronchospasm.
 treatments. 6. Fluids during meals can prompt follow up
10. Monitor ABGs, pulse increase gastric checkup and to
oximetry, chest x- ray. distension and pressure always bring or
on the diaphragm.
have the
7. Anticholinergic
medications are the first prescribed
line drugs for clients with medication/s on
this condition. hand in case
8. Humidity helps reduce asthma occurs.
viscosity of secretions,
facilitating expectoration
and may.
9. Breathing exercises help
enhance diffusion,
nebulizer medications
can reduce
bronchospasm and
stimulate expectoration.
10. Establishes baseline for
monitoring progression/
regression of disease
process.