Ineffective Airway Clearance.

PLANNING/IMPLEMENTATION/EVALUATION (See Grading Rubric for NCP Criteria)
Nursing Diagnosis Ineffective Airway Clearance r/t trachea-bronchial infection, retained secretions AEB nonproductive cough,
change in respiratory rate with secretions
Long Term Goal Pt. will maintain patent airway
Outcome Criteria
One outcome criteria for each
intervention. Number each one.
Interventions
Label each intervention as:
Assess/Monitor/Independent
Dependent/Teaching/Collaboration
Rationale
Answers why, how, what your interventions will
help solve, prevent or lessen the stated problem
specific to this patient.
Monitoring the respiratory rate will allow the nurse
to determine if the patient is having sufficient
oxygen intake. Due to this patient having
pneumonia and respiratory complications the
respiratory rate will increase. A change in
respiratory rate may show an exacerbation in the
infection. Respirations below 12 and over 12-24
may indicate a need for immediate intervention.
Monitoring provides a means for comparison with
baseline. (NDH 129)
Evaluation
Evaluate the patient
outcome NOT the
intervention
M: This patient
maintained a
respiratory rate of
12-20.
Ongoing
1) Pt. will have respirations of
12-20 as assessed q4hrs
Monitor respiratory rate, rhythm
and depth q4hrs
2) Pt will maintain temp of 9799 as measured q4hr
Assess temperature q4hr and prn
An increase in temperature indicates infection.
This pt. has pneumonia which is an infection in the
lungs. If a temp, spikes while on the antibiotic, it
may indicate the infection is getting worse or going
septic. This patient is also at a risk for aspiration,
fever can be related to infection in the lung due to
aspiration. This can affect proper mobilization of
secretions for the patient. (NCP 130, Nursing 102
Lecture notes Respiratory Rationales)
M: This patient
maintained a temp of
97-99.
Resolved
3) Pt. will have clear lung
sounds in two days.
Assess lung sounds q4hrs
Auscultation assesses the movement of air through
the tracheal bronchial tree and detects mucous or
obstructed airways. Abnormal sounds result from
air passing through moisture, mucus or narrowed
airways. Adventitious lung sounds are extra breath
sounds that are abnormal including crackles,
rhonchi, wheezes and pleural rubs. Crackles would
P: This patient’s lung
sounds were rhonchi
bilaterally. This
patient’s lung sounds
were cleared with an
effective cough
within 2 days
indicate fluid in the lung tissue, diminished lung
sounds over an obstruction, rhonchi indicate
air moving through secretions, these would
indicate ineffective airway clearance. (Lewis
page 507-512)
Ongoing
4) Patient will have moist
mucous membranes and
pink skin as observed q4hrs
Assess skin color and mucous
membranes q shift and prn
Pale or cyanotic color indicates an increased
concentration of deoxygenated blood and
indicates that breathing is no longer effective
to maintain adequate oxygenation of tissues.
Central cyanosis of the tongue and oral
mucosa is an indicator of severe hypoxia that
can be related to respiratory distress caused
by retained secretions in the airway. (NCP
page 31, NDH page 403)
M: This patient’s skin
color was pink, and
moist mm.
Ongoing
5) Patient will maintain 02 sat
95-100% as assessed q4hrs
Administer oxygen as 2L n/c as
ordered by MD q day and prn
Dependent
O2 therapy is frequently used in the treatment of
pneumonia and COPD and other problems
associated with hypoxemia. Long term therapy
improves survival, cognitive performance and
sleep. The goal of O2 therapy is the supply the
patient with adequate O2 carrying ability to the
blood and deliver O2 at concentrations than
ambient air. This patient has pneumonia,
which includes secretions in the alveoli, which
make it difficult to move air through the alveoli.
(Lewis 618)
M: This patient
maintained 02 sat
95-100%
Resolved
Elevate HOB at 90 degrees at all
times
Independent
An upright position allows for maximal lung
expansion and chest expansion. While lying
flat causes abdominal organs to shift towards
the chest, which crowds the lungs and makes
it difficult to breathe. A HOB up 90 degrees
optimizes respirations and creates a
decreased incident of pneumonia related to
aspiration. Maintaining high fowlers with and
after meals can help decrease aspiration
pneumonia. NDH 129,151
P: This patient
exhibited no signs of
aspiration, but the
patient did have
issues clearing
secretions even in
high fowler’s.
Resolved
6) Patient will exhibit no signs
of aspiration at all times
7) Patient will have
productive cough within 2
days
Assess for presence of cough and
characteristics of sputum q4hrs and
prn
Independent
A cough is an abnormal finding. It is important to
assess this to monitor for change in frequency of
cough and whether the cough has become more
productive. Note the sound of the cough,
frequency and time span associated with the
cough. It is also important to assess the sputum for
color, frequency, consistency and odor. Normal
sputum is clear or gray and minimal, abnormal
sputum is green, yellow, or bloody and may be
copious. These assessments are important for the
patient with pneumonia to monitor for a diversion
from the baseline and progression. (NDH 130)
U: This patient was
having difficulties
expelling sputum and
had a nonproductive
cough without the
use of suctioning.
Ongoing
8) Patient will effectively self
suction retained secretions
as needed
Encourage self suctioning as
needed and q2hrs
Independent
Oropharyngeal blind suctioning (suctioning without
a tracheal tube in place) is done if the patient is
unable to expectorate secretions. The need for
suctioning is indicated with coarse crackles,
rhonchi over large airways, moist cough, increase
in RR, SOB, restlessness and the presence of
excessive secretions. The use of suctioning can
assist in mobilizing secretions and creating a
patent airway for the patient. This patient had SOB
r/t retained secretions and the need for suctioning
created a patent airway. (Lewis 1753, 530)
P: When the patient
suctioned, secretions
were cleared but had
to suction
continuously and had
difficulty getting all
secretions.
Ongoing
9) Patient will consume 20003000ml/24hrs
Encourage adequate PO fluid intake
q shift
Independent
Thick and viscous secretions are hard to expel.
Adequate fluid intake (2-3L/day) keeps secretions
thin and easier to move. Water is the most
physiological compatible expectorant. Encouraging
fluids liquefy the secretions, which will improve
expectoration of secretions, prevent mucous plugs,
which can cause hypoxia or atelectesis. Increased
fluids will prevent bacterial growth of
microorganisms as a stasis of secretions that could
become a medium for bacterial growth, such as
pneumonia. (Lewis 1753, Nursing 102 Lecture
Notes, Respiratory Rationales)
M: This patient
consumed 20003000ml/day of fluids
Resolved
10) Patient will have mobilization
of secretions by day 2
11) Patient will cough deeply 2
times q2hr
12) Patient will demonstrate use
of IS 10x/hr
Reposition patient q2hrs while in
bed
Independent
Teach patient effective cough
methods q day
Independent
Encourage patient to use incentive
spirometer q hour and prn
Independent
Turning and positioning the patient every 2 hours
promotes loosening and mobilization of secretions,
circulation and prevents thoracic compression and
inhibition of air through the lungs. This allows for
better aeration and gas exchange of O2 and CO2.
Some positions the patient may be repositioned
are side lying from left to right side, increasing the
HOB to prevent aspiration pneumonia and
positioning from side lying to back every 2 hours. It
is very important for to be turned every 2 hours
because they are paraplegic and do not have the
ability to reposition themselves on their own and be
ambulatory. It is crucial to reposition for the
mobilization of secretions and airway clearance for
this patient. ( Nursing 102 Lecture Notes,
Respiratory Rationales)
If secretions are obstructing the airway, encourage
the patient to cough. The patient with a
neuromuscular weakness (paraplegia) may not be
able to generate sufficient pressures to produce an
effective cough. Augmented cough may be
beneficial to these patients. Perform by placing the
palm of your hands on the patient’s abdomen
below the xiphoid process and as the patient’s
ends a deep inspiration and begins expiration,
move your hands forcefully downward, increasing
abdominal pressure and facilitating a cough.
Another effective cough technique is the huff
cough, which prevents the glottis from closing
during the cough. These techniques may increase
expiratory flow and facilitate secretion clearance.
(Lewis page 1752-1753)
Incentive spirometer facilitates adequate clearance
of secretions and prevents atelectasis. IS
encourages voluntary deep breathing by providing
visual feedback to patients about inspiratory
volume. IS also promotes deep breathing and
prevents or treats atelectasis. It is important for this
patient to use the IS because they are bed/chair
ridden and also have respiratory complications of
COPD and pneumonia. (P+P page 848)
P: This patient was
t&p 2hrs, and the
mobilization of
secretions became
more effective than
they were on day of
admission
Resolved
M: This patient used
the augmented
cough and expelled
secretions and then
suctioned.
Ongoing
P: This cannot be
evaluated because
the IS was
introduced to patient
on 10/4. Patient was
encouraged to use
this 10x/hour. The
patient demonstrated
understanding by
showing how to use
IS. Ongoing
Outcome Criteria
Interventions
Rationale
An Acapella is a hand held device that uses
pulmonary expiratory pressure and airway
vibrations to mobilize airway secretions. The
patient may also inhale through it and nebulizer
can be attached to the Acapella. This device is
important for this patient because the patient has
neuromuscular weakness and may be difficult for
the patient to expectorate secretions on their own.
(Lewis page 624)
13) Pt. will demonstrate use of
Acapella qhr
Encourage use of Acapella q hour
while awake and prn
Independent
14) Pt. will show decreased
signs of infection (decreased
temp, decreased chest pain,
improved breathing) by day 2
Administer Vancomycin 1000mg
IVPB q12hrs per MD order
Dependent
Vancomycin (Vancocin) is used as a bactericidal
against susceptible death, treatment of potentially
life threatening infections when less toxic antiinfectives are contraindicated such as pneumonia.
Prompt treatment with the appropriate antibiotic
almost always cures bacterial causes of
pneumonia. Indications of improvement with
Vancomycin include decreased temperature,
improved breathing, reduced chest pain and
decreased in trachea-bronchial secretions. (Lewis
549, Davis Drug Book ebook)
15) Pt. will show no signs of
aspiration daily
Provide mouth care to patient b.i.d
and prn
Providing meticulous mouth care consists of
brushing teeth at least two times a day. Good oral
care can prevent contaminations of the mouth and
prevent food and oral secretions to be aspirated.
Dental care has been shown to be effective in
preventing aspiration and hospital acquired
pneumonia. (NDH 153).
Evaluation
M: This patient
demonstrated use of
the Acapella every
hour and assisted in
the mobilization of
secretions for the
patient.
Ongoing
M: This patient
exhibited decreased
signs of infection
Resolved
M: This patient
showed no signs of
excessive secretions
or food around
mouth. The pt.
exhibited no signs of
aspiration while
hospitalized.

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