A situation in which individuals experienced a real threat or risk of respiratory status in relation to the inability to effectively cough.
Related Factors:
- Decreased energy and fatigue
- Ineffective cough
- Tracheobronchial infection
- Tracheobronchial obstruction (including foreign body aspiration)
- Copious tracheobronchial secretions
- Perceptual/cognitive impairment
- Impaired respiratory muscle function
- Trauma
Major Data
- Ineffective cough or no cough
- The inability to remove airway secretions.
Minor Data
- Abnormal breath sounds
- The frequency, depth of abnormal breathing rhythm
Expected Outcomes
- Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
Nursing Intervention Nursing Care Plan for Ineffective Airway Clearance
- Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.
- Auscultate lungs for presence of abnormal or adventitious breath sounds, as in the Following:
- Decreased or absent breath sounds These May indicate presence of mucus plug or other major airway obstruction.
- These wheezing May indicate Increasing airway resistance.
- These sounds Coarse May indicate presence of fluid along larger Airways.
- Assess respirations: note quality, rate, pattern, depth, flaring of nostrils, dyspnea on Exertion, evidence of splinting, use of accessory muscles, and position for breathing. Abnormality indicates respiratory compromise.
- Assess changes in mental status. Increasing lethargy, confusion, restlessness, and / or irritability cans be early Signs of cerebral hypoxia.
- Assess changes in Vital Signs and temperature. Tachycardia and hypertension May be related to Increased work of breathing. Fever May develop in response to retained secretions / atelectasis.
- Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough (eg, respiratory muscle fatigue, severe bronchospasm, or thick Tenacious secretions).
- Note presence of sputum; assess their quality, color, amount, odor, and consistency. May this be a result of infection, bronchitis, chronic smoking, or other condition. A sign of infection is discolored sputum (no longer clear or white); an odorant May be present.
Nursing Care Plan for Impaired Gas Exchange
