Introduction to Nursing Diagnosis: Ineffective Airway Clearance
Nursing diagnosis is a method of identifying patient needs, and developing a plan to meet those needs. NANDA-International (NANDA-I) is a professional organization devoted to the promotion, development, and standardization of nursing diagnoses worldwide. One of the diagnoses identified by NANDA-I is ineffective airway clearance.
NANDA Nursing Diagnosis Definition
The NANDA-I diagnosis for ineffective airway clearance is defined as “inadequate and ineffective pulmonary gas exchange secondary to retention of secretions or obstructive material in the airways”.
- Dyspnea and difficulty breathing
- Coughing with expectoration
- Productive and/or dry cough
- Pleuritic chest pain
- Maintained vital signs
- Presence of rales and/or rhonchi
- Diminished breath sounds
- Partial airway obstruction from edema or secretions
- Impaired ciliary function or findings suggestive of bronchitis
- Exposure to irritants including smoke and airborne pollutants
- Inadequate humidity
- Inadequate nutrition
- Delayed development of airway Muscle control
- Altered consciousness
- Age less than 1 year old
- Inability to clear secretions
- Previous or current smoking history
- Complex medical regimen
- Chronic respiratory disease
- Increasing airway obstruction
- Weight loss
- Suboptimal oxygenation
- Respiratory complications
- Activity intolerance
Suggestions for Use
- Administer humidified oxygen or aerosol with or without broncho-dilator medication
- Prevent aspiration
- Assess for cause of airway clearance problem
- Keep patient in upright position with head elevated
- Perform suctioning to promote airway clearance and prevention of atelectasis
- Provide education about airway hygiene
Suggested Alternative NANDA Diagnoses
- Ineffective Breathing Pattern
- Ineffective Airway Clearance related to Shortness of Breath
- Impaired Gas Exchange related to Respiratory Infection
- Ineffective Therapeutic Regimen Management
- Risk for Aspiration
- Readiness for Enhanced Airway Clearance
- This nursing diagnosis can be used routinely for patients admitted with an acute or chronic respiratory condition.
- It can also be used for patients at risk for Caregiver/Family disappointment related to exacerbation of the illness.
- It is important to consider the patient’s condition and activity level before initiating interventions.
- Eating small meals during the day or avoiding food two hours prior to bedtime may decrease risk for problems.
- Effective Airway Clearance: The patient’s lung capacity is maintained, vocal sounds are strong and clear, and sputum-producing coughing is absent.
- Gas Exchange: The patient is able to exchange oxygen and carbon dioxide without impairment.
- Safety Awareness: The patient takes appropriate action to ensure his/her safety by recognizing and avoiding situations that could be hazardous.
- Ventilation: The patient produces adequate and efficient breath sounds.
- Self-Care: The patient demonstrates acceptable performance of daily activities and self-care.
- Comfort Level: The patient is free from physical discomfort during breathing.
- Airway Clearing Techniques: The use of techniques such as chest physical therapy (CPT), percussion, and postural drainage to help clear the airway and improve ventilation.
- Monitor Respiratory Rate: Monitoring the patient’s respiratory rate and assessing if additional oxygen augmentation is needed.
- Activity Planning: Developing a plan of care and providing instructions to the patient based on their ability to tolerate activity.
- Oxygen Therapy: Administering oxygen therapy when indicated to improve oxygen saturation levels.
- Mucus Reduction Strategies: Promoting methods to reduce production and accumulation of secretions that include frequent hydration, humidification, and airway suctioning.
- Environmental Control: Taking steps to eliminate environmental sources of pollution and allergens, including controlling exposure to irritants.
In conclusion, nursing diagnosis of Ineffective Airway Clearance is an important tool in nursing care. It is critical to accurately assess and diagnose patients who have this condition in order to provide the best possible care and outcomes. Knowledge of the various types of interventions and treatments available can assist nurses in meeting the goals of patient care.
- What is the NANDA Nursing Diagnosis for Ineffective Airway Clearance?
- The NANDA Nursing Diagnosis for Ineffective Airway Clearance is “inadequate and ineffective pulmonary gas exchange secondary to retention of secretions or obstructive material in the airways”.
- What are the associated problems with Ineffective Airway Clearance?
- The associated problems with Ineffective Airway Clearance include increasing airway obstruction, weight loss, suboptimal oxygenation, and respiratory complications.
- What are the suggestions for using interventions to treat Ineffective Airway Clearance?
- Suggestions for using interventions to treat Ineffective Airway Clearance include administering humidified oxygen or aerosol with or without broncho-dilator medications, preventing aspiration, assessing for the cause of airway clearance problem, keeping the patient in an upright position with head elevated, performing suctioning to promote airway clearance, and providing education about airway hygiene.