NURSING CARE PLAN
Ineffective Airway Clearance
Inability to clear secretions or obstructions from the respiratory tract to maintain a
clear airway.
Breathing comes naturally and effortlessly to everyone. But there are some who are
incapable of keeping their airways clear and their lungs healthy. Maintaining a
patent airway has always been vital to life. When problem concerning the airway
happens, coughing takes place, which is the main mechanism for clearing it.
However, coughing may not always be easy to everyone especially to those
patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular
weakness. Mechanisms that exist in the lower bronchioles and alveoli to maintain
the patency of the airway include the mucociliary system, macrophages, and the
lymphatics. Also, anesthesia and dehydration can alter the function of the
mucociliary system. Thus, increased production of secretions in conditions such
as pneumonia and bronchitis can oppress these mechanisms.
Ineffective Airway Clearance can be an acute (e.g., postoperative recovery) or
chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway
clearance are the aged individuals who have an increased
incidence of emphysema and a higher prevalence of chronic cough or sputum
0
Page
production.
0
, There is a wide range of airway clearance interventions that nurses can choose
from when they are teaching the patients and family members the strategies of
secretion removal. In general, these interventions are done to maintain a patent
airway, improve comfort and ease of breathing, improve pulmonary ventilation and Page | 1
oxygenation, and to prevent risks associated with oxygenation problems.
1 Related Factors
2 Defining Characteristics
3 Goals and Outcomes
4 Nursing Assessment
5 Nursing Interventions
Related Factors
Here are some factors that may be related to Ineffective Airway Clearance:
Airway spasm/asthma
Copious and tenacious tracheobronchial secretions
Decreased energy and fatigue
Impaired respiratory muscle function
Neuromuscular function
Presence of artificial airway
Tracheobronchial infection
Tracheobronchial obstruction (foreign body aspiration)
Pathophysiologic
Related to excessive or thick secretions secondary to:
Allergy
Cardiac or pulmonary disease
Exposure to noxious chemical
, Infection
Inflammation Smoking
Related to immobility, stasis of secretions, and ineffective cough secondary to:
Page | 2
Central nervous system (CNS) depression/head trauma
Cerebrovascular accident (stroke)
Guillain-Barre syndrome
Multiple sclerosis
Myasthenia gravis
Quadriplegia
Treatment Related
Anesthesia (general or spinal)
Sedating or paralytic effects of medications, drugs, or chemicals
Suppressed cough reflex
Tracheostomy
Situational (Personal, Environmental)
Related to immobility secondary to:
Anxiety
Cognitive impairment
Fatigue
Fear
Pain
Perception
Surgery
Trauma
Related to extremely high or low humidity
, For infants, related to placement on stomach for sleep
Exposure to cold, laughing, crying, allergens, smoke
Defining Characteristics Page | 3
Ineffective Airway Clearance is characterized by the following signs and
symptoms:
Abnormal breath sounds (crackles, rhonchi, wheezes)
Abnormal respiratory rate, rhythm, and depth
Dyspnea
Excessive secretions
Hypoxemia/cyanosis
Inability to remove airway secretions
Ineffective or absent cough
Orthopnea
Goals and Outcomes
The following are the common goals and expected outcomes for Ineffective Airway
Clearance.
Patient will maintain clear, open airways as evidence by normal breath
sounds, normal rate and depth of respirations, and ability to effectively
cough up secretions after treatments and deep breaths.
Patient will demonstrate increased air exchange.
Patient will classify methods to enhance secretion removal.
Patient will recognize the significance of changes in sputum to include
color, character, amount, and odor.
Patient will identify and avoid specific factors that inhibit effective
airway clearance.
Ineffective Airway Clearance
Inability to clear secretions or obstructions from the respiratory tract to maintain a
clear airway.
Breathing comes naturally and effortlessly to everyone. But there are some who are
incapable of keeping their airways clear and their lungs healthy. Maintaining a
patent airway has always been vital to life. When problem concerning the airway
happens, coughing takes place, which is the main mechanism for clearing it.
However, coughing may not always be easy to everyone especially to those
patients with incisions, trauma, respiratory muscle fatigue, or neuromuscular
weakness. Mechanisms that exist in the lower bronchioles and alveoli to maintain
the patency of the airway include the mucociliary system, macrophages, and the
lymphatics. Also, anesthesia and dehydration can alter the function of the
mucociliary system. Thus, increased production of secretions in conditions such
as pneumonia and bronchitis can oppress these mechanisms.
Ineffective Airway Clearance can be an acute (e.g., postoperative recovery) or
chronic (e.g., CVA or spinal cord injury) problem. High-risk for ineffective airway
clearance are the aged individuals who have an increased
incidence of emphysema and a higher prevalence of chronic cough or sputum
0
Page
production.
0
, There is a wide range of airway clearance interventions that nurses can choose
from when they are teaching the patients and family members the strategies of
secretion removal. In general, these interventions are done to maintain a patent
airway, improve comfort and ease of breathing, improve pulmonary ventilation and Page | 1
oxygenation, and to prevent risks associated with oxygenation problems.
1 Related Factors
2 Defining Characteristics
3 Goals and Outcomes
4 Nursing Assessment
5 Nursing Interventions
Related Factors
Here are some factors that may be related to Ineffective Airway Clearance:
Airway spasm/asthma
Copious and tenacious tracheobronchial secretions
Decreased energy and fatigue
Impaired respiratory muscle function
Neuromuscular function
Presence of artificial airway
Tracheobronchial infection
Tracheobronchial obstruction (foreign body aspiration)
Pathophysiologic
Related to excessive or thick secretions secondary to:
Allergy
Cardiac or pulmonary disease
Exposure to noxious chemical
, Infection
Inflammation Smoking
Related to immobility, stasis of secretions, and ineffective cough secondary to:
Page | 2
Central nervous system (CNS) depression/head trauma
Cerebrovascular accident (stroke)
Guillain-Barre syndrome
Multiple sclerosis
Myasthenia gravis
Quadriplegia
Treatment Related
Anesthesia (general or spinal)
Sedating or paralytic effects of medications, drugs, or chemicals
Suppressed cough reflex
Tracheostomy
Situational (Personal, Environmental)
Related to immobility secondary to:
Anxiety
Cognitive impairment
Fatigue
Fear
Pain
Perception
Surgery
Trauma
Related to extremely high or low humidity
, For infants, related to placement on stomach for sleep
Exposure to cold, laughing, crying, allergens, smoke
Defining Characteristics Page | 3
Ineffective Airway Clearance is characterized by the following signs and
symptoms:
Abnormal breath sounds (crackles, rhonchi, wheezes)
Abnormal respiratory rate, rhythm, and depth
Dyspnea
Excessive secretions
Hypoxemia/cyanosis
Inability to remove airway secretions
Ineffective or absent cough
Orthopnea
Goals and Outcomes
The following are the common goals and expected outcomes for Ineffective Airway
Clearance.
Patient will maintain clear, open airways as evidence by normal breath
sounds, normal rate and depth of respirations, and ability to effectively
cough up secretions after treatments and deep breaths.
Patient will demonstrate increased air exchange.
Patient will classify methods to enhance secretion removal.
Patient will recognize the significance of changes in sputum to include
color, character, amount, and odor.
Patient will identify and avoid specific factors that inhibit effective
airway clearance.
