Ineffective Cleaning of Airways: Understanding the NANDA Nursing Diagnosis
Cleaning of airways refers to the process by which mucus and other secretions are removed from the respiratory tract. When this process is ineffective, it can lead to a variety of problems and complications such as infection, inflammation and difficulty breathing. In the nursing field, this is referred to as “Ineffective Cleaning of Airways” and is classified as a NANDA nursing diagnosis.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Ineffective Cleaning of Airways” is: “A difficulty in clearing secretions from the respiratory tract as evidenced by increased frequency of coughing, difficulty breathing, chest congestion, and/or decreased ability to speak.”
Defining Characteristics (Subjectives and Objectives)
- Chest congestion
- Difficulty breathing
- Decreased ability to speak
- Chronic obstructive pulmonary disease (COPD)
- Chest injury
- Neuromuscular disorders
Individuals who are at a higher risk for developing “Ineffective Cleaning of Airways” include:
- Elderly adults
- Individuals with chronic lung disease
- Individuals with asthma
- Individuals with chest injury
- Individuals with neuromuscular disorders
- Acute respiratory failure
Suggestions for Use
- Assess patient’s ability to clear secretions by observing coughing, sputum and breathing pattern
- Administer bronchodilators, mucolytics, or other medications as ordered
- Instruct patient and family in techniques such as deep breathing, coughing, and use of incentive spirometer to clear secretions
- Implement measures to prevent infections, such as proper hand hygiene and aseptic technique
- Monitor patient for signs of respiratory distress and take appropriate action as necessary
Suggested Alternative NANDA Diagnoses
- Ineffective Airway Clearance
- Impaired Gas Exchange
- Ineffective Breathing Pattern
- Risk for Injury related to impaired physical mobility
- Impaired Spontaneous Ventilation
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the ineffective cleaning of airways, such as pneumonia or COPD.
- It is important to monitor the patient’s response to interventions and adjust as necessary.
- It is also important to consider the patient’s overall respiratory history and any previous respiratory events they may have experienced.
- In cases where the patient is experiencing severe ineffective cleaning of airways, referral to a respiratory therapist or pulmonologist may be necessary.
List of NOC Results with Explanation
- Airway Clearance: This outcome measures the patient’s ability to clear secretions from the respiratory tract and assess the effectiveness of interventions.
- Breathing Pattern: This outcome measures the patient’s breathing pattern, which can indicate changes in airway clearance and overall respiratory function.
- Oxygenation Status: This outcome measures the patient’s oxygenation status, which can be affected by ineffective cleaning of airways.
- Tissue Perfusion: This outcome measures the patient’s tissue perfusion, which can be affected by ineffective cleaning of airways.
List of NIC Interventions with Explanation
- Airway Clearance Techniques: This intervention involves techniques such as coughing, deep breathing, and use of an incentive spirometer to improve the patient’s ability to clear secretions from the respiratory tract.
- Medications Management: This intervention involves administering medications such as bronchodilators, mucolytics, or other as ordered to improve airway clearance and overall respiratory function.
- Chest Physical Therapy: This intervention involves techniques to mobilize secretions and improve lung expansion to enhance airway clearance and overall respiratory function.
- Infection Control: This intervention involves implementing measures to prevent infections, such as proper hand hygiene, to protect the patient’s overall health and respiratory function.
Ineffective Cleaning of Airways is a serious concern that can lead to a variety of problems and complications. By understanding the NANDA nursing diagnosis and utilizing appropriate interventions, nurses can help to promote optimal respiratory function and prevent further complications in at-risk patients.