Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway
Smoking; secondhand smoke; smoke inhalation
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls
Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]
Cough, ineffective/absent; excessive sputum
Changes in respiratory rate and rhythm
Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic fibrosis, neuromuscular diseases, inhalation injuries
Client Will (Include Specific Time Frame)
Maintain airway patency.
Expectorate/clear secretions readily.
Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
Verbalize understanding of cause(s) and therapeutic management regimen.
Demonstrate behaviors to improve or maintain clear airway.
Identify potential complications and how to initiate appropriate preventive or corrective actions.
NURSING PRIORITY NO.1
To maintain adequate, patent airway:
Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.
Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors.
Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.
NURSING PRIORITY NO.2
To mobilize secretions:
Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.
NURSING PRIORITY NO.3
To assess changes, note complications:
Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.
Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress.
Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.
NURSING PRIORITY NO.4
To promote wellness (Teaching/Discharge Considerations):
Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.
Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association).
Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)
Related factors for individual client.
Breath sounds, presence/character of secretions, use of accessory muscles for breathing.
Character of cough/sputum.
Plan of care and who is involved in planning.
Client’s response to interventions/teaching and actions performed.
Attainment/progress toward desired outcome(s).
Modifications to plan of care.
Long-term needs and who is responsible for actions to be taken.
Specific referrals made.