Nursing Diagnoses Ineffective Airway Clearance

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Related to: (Specify: tracheobronchial infection, obstruction, secretions.)

Defining Characteristics: (Specify, e.g., abnormal breath sounds: fine or coarse crackles, rhonchi, wheezes, changes in rate or depth of respirations, tachypnea, cyanosis, fever, provide data.)

Related to: Decreased energy and fatigue.

Defining Characteristics: (Specify, e.g., ineffective cough with or without sputum, labored respirations, inability to feed self, sleeplessness, lack of activity, weakness.)

Goal: Infant/child will experience improved airway clearance by (date/time to evaluate). Outcome Criteria

V Return of respiratory status to baseline parameters for rate, depth and ease (specify).

V Breath sounds clear bilaterally.

V Ability to cough up and remove secretions that are thin and clear. NOC: Respiratory Status: Airway Patency, Ventilation

INTERVENTIONS

Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time; note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow (hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency).

Assess breath sounds by auscultation,

RATIONALES

Reveals rate and type of respirations (baselines or deviations) that are related to age and size of the infant/child, changes that indicate obstruction and consolidation of airways and lungs resulting in a decrease in lung surface for gas diffusion, extreme changes in depth are abnormal, head bobbing indicates dyspnea in the infant and fatigue causing neck flexion, grunting indicates respiratory distress.

Provides indication of patent airways consolidation by percussion and fremitus (specify when).

Assess skin color changes, distribution and duration of cyanosis (nail beds, skin, mucous membranes, circumoral) or pallor (specify frequency).

Assess cough (moist, dry, hacking, paroxysmal, brassy, or croupy): onset, duration, frequency, if occurs at night, during day, or during activity; mucus production: when produced, amount, color (clear, yellow , green), consistency (thick, tenacious, frothy); ability to expectorate or if swallowing secretions, stuffy nose or nasal drainage.

Elevate head of bed at least 30° for child and hold infant and young child in lap or in an upright position with head on shoulder; older child may sit up and rest head on a pillow on overbed table (specify); check child's position frequently to ensure child does not slide down in bed.

Reposition on sides q 2h; position child in proper body alignment.

Provide fluids at frequent intervals over 24-h time periods, specify amounts; encourage clear liquids, and avoid milk.

Provide for periods of rest by organizing procedures and care and disturbing infant/child as little as possible in acute stages of illness.

Perform postural drainage between meals using gravity, percussion, and by auscultation, revealing crackles heard in the presence of secretions (fine and coarse), rhonchi (audible and palpable) in larger airway obstruction and wheezes in small bronchiolar narrowing (inspiration and expiration), diminished breath sounds in presence of decreased airflow and lung consolidation; indication of consolidation by presence of dullness on percussion and increased fremitus, decreased functional lung area by presence of tympany on percussion.

Reveals presence and degree of cyanosis, indicating an uneven distribution of gas and blood in the lungs, and alveolar hypoventilation resulting from airway obstruction, the weakness of muscles used in respiration or respiratory center depression.

Reveals characteristics of cough as an indication of a respiratory condition that may be produced by infection or inflammation; small and narrow airways of an infant/child and the difficulty to cough up secretions cause obstruction from the stasis of secretions, which lead to infection and change in respiratory status.

Positioning facilitates chest expansion and respiratory efficiency by reducing pressure of abdominal organs on diaphragm.

Prevents accumulation and pooling of secretions.

Maintains hydration status, and clear liquids liquefy and mobilize secretions; milk tends to thicken secretions.

Prevents unnecessary energy expenditure resulting in fatigue.

Promotes removal of secretions and sputum from airways; percussion and vibration unless contraindicated; hold infant on lap; support child with pillows. Teach parents. positioning.

Assist to perform deep breathing and coughing exercises in child when in a relaxed position for postural drainage unless procedures are contraindicated; use incentive spirometer in older child, blowing up balloon, blowing bubbles, blowing a pinwheel or blowing cotton balls across the table in younger child (specify).

Suction nasal and/or oropharyngeal passages, if needed and appropriate, using correct catheter and method, amount of negative pressure, and time limits (specify); orotracheal with the administration of oxygen before and after suctioning if needed; use bulb syringe to suction mucus from infant's nose; catheter size is age dependent (specify), maximum negative pressure of 60 to 90 cm H2O with time limit of 5 seconds for infant, and 90 to 110 cm H2O with 5 second time limit for child.

Administer pain medications as ordered (specify drug, dose, route, and time); assess level of pain using appropriate pain assessment tools (specify).

Provide mouth care qid and after suctioning.

Provide toys, games for quiet play, and a quiet environment (specify).

Place airway maintenance equipment and supplies at bedside (resuscitation bag, oxygen and suction equipment, endotracheal tube, tracheostomy tube, and supplies).

Administer medications (mucolytics, bronchodilators, antibiotics, expectorants, decongestants, and/or antihistamines) orally, parenterally, via aerosol therapy with hand-held measured-dose inhaler, small volume nebulizer, IPPB according to physician order (provides specifics).

vibration loosen and dislodge secretions, and gravity drains the airways and lung segments through Promotes deeper breathing by enlarging tracheobronchial tree and initiating cough reflex to remove secretions.

Removes secretions when cough is nonproductive (older child if unable to regulate cough or breathe through mouth); if nose obstructed by mucus (infant or young child); type of suctioning dependent on amount, ability to drain or cough up, breath sounds in upper airways; prolonged suctioning causes vagal stimulation, oxygen desaturation, and bradycardia, and the use of high pressure damages the mucous membrane lining of airways

Promotes comfort during deep breathing exercises and coughing to aid in the removal of secretions.

Prevents drying of oral mucous membranes.

Prevents excessive energy expenditure and need for additional oxygen consumption, which changes respiratory status while still providing moderate activity and diversion of play.

Provides immediate access to emergency equipment for interventions to treat airway obstruction if needed.

(Specify drug action, e.g., treats conditions affecting secretions, infection by liquefying secretions and enhancing outflow and removal of secretions (mucolytics, expectorants), relieving bronchospasms (bronchodilators), destroying infectious agents by interfering with cell way synthesis

Instruct parents/child in handwashing techniques.

Instruct parents/child to avoid contact with those who have respiratory infections.

Inform parents of need to maintain or increase fluids, type of fluids to include and avoid, to offer small amounts (q 1h to infant and 50 to 100 ml to child q 2h) during waking hours using small cup or straw.

Teach the importance of physical exercise; activities with short burst of energy (baseball, sprinting, skiing) are recommended.

Recommend swimming as a form of physical exercise.

Teach parents to use bulb syringe to remove mucus from infant's nose, demonstrate and instruct in oropharyogeal suctioning if appropriate; allow return demonstration.

Teach parents and possibly older child (specify) administration of medications via proper route with name and action of each drug: dosage; why given; frequency; time of day or night; side effects to report; how to administer in food—crushed, chewable, by measured dropper, or other recommended form; and method (nose drops, inhaler).

Instruct parents and child to administer aerosols with use of hand-held inhaler, small volume nebulizer using oral or mask breathing apparatus; assembling of devices, cleaning and care of reusable supplies and equipment (specify).

(antibiotics), reducing allergic responses and discomfort of nose stuffiness (decongestant, antihistamines), and by suppressing cough (cough suppressants) unless cough is desired to bring up secretions.)

Prevents transmission of microorganisms from touching or handling supplies, touching face of child by parent(s)/ child without handwashing.

Prevents transmission of microorganisms via airborne droplets.

Maintains hydration.

Promotes better tolerance than endurance exercises.

Promotes saturation of inhaled air with moisture; exhaling underwater prolongs expiration and improves end expiratory pressures.

Removes secretions in those too weak or unable to cough up secretions, removing mucus from nose of infant enhances breathing (obligate breather).

Ensures compliance with correct drug dosage and other considerations for administrations for desired results, and what to do if side effects occur.

Promotes proper administration and independence of child depending on age and ability.

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Responses

  • DAVID
    What body systems do you assess for ineffective airway clearance?
    1 year ago

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