00031 Ineffective Cleaning Of Airways

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00031
Nanda label: ineffective cleaning of the airways
Diagnostic focus: airway cleaning
Approved 1980 • Revised 1996, 1998, 2017, 2020 • Evidence level 3.3

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « ineffective cleaning of the airways is defined as: reduction of the ability to eliminate the secretions or obstructions of the respiratory tract to maintain the permeable airways. >

Definite characteristics

  • Absence of cough
  • Abnormal respiratory sounds
  • Respiratory rhythm alteration
  • Alteration of thoracic percussion
  • Alteration of the thoraco-vocal fremite
  • Bradypnea
  • Cianosis
  • Difficulty verbalizing
  • Decrease in respiratory sounds
  • Excessive amount of sputum
  • hypoxemia
  • ineffective cough
  • Ineffective elimination of sputum
  • Nasal flutter
  • Orthopnea
  • Psychomotor agitation
  • Subcostal retraction
  • Tachypnea
  • Use of breathing accessory muscles

Related factors

  • Dehydration
  • Excessive mucus
  • Exposure to harmful substances
  • Fear of pain
  • Foreign body on the airway
  • Lack of attention to passive smoker
  • mucous plug
  • Retention of secretions
  • smoking

Risk population

  • Children
  • Infants

Associated problems

  • Airway spasm
  • Airway allergy
  • asthma
  • Chronic obstructive pulmonary disease
  • Congenital heart disease
  • Severe condition
  • Alveolar exudate
  • General anesthesia
  • Bronchial wall hyperplasia
  • Neuromuscular diseases
  • Respiratory tract infection

Suggestions of use

Use the main defining characteristics described in Table 10 to differentiate this label from the other two possible respiratory diagnoses. If the reflection of cough and nauseous are ineffective or absent due to anesthesia, use aspiration risk instead of ineffective cleaning of respiratory tract to focus on preventing aspiration rather than teaching the patient to cough effectively. P>

Suggested alternative diagnostics

  • Aspiration, risk of
  • Gaseous exchange, deterioration of
  • Respiratory pattern, ineffective

NOC Results

  • Respiratory status: permeability of the respiratory tract: open and clear tracheobronchial tree to perform the gas exchange
  • Respiratory status: ventilation: input and output of the lungs
  • Precautions to avoid aspiration: Personal actions aimed at preventing the passage of liquids and solid particles to the lung
  • Response to mechanical ventilation: Adult: Alveolar exchange and tissue perfusion are supported by mechanical ventilation

Evaluation objectives and criteria

  • • Demonstrates an effective cleaning of the respiratory tract, which is manifested by: precautions to avoid aspiration; Respiratory state: permeability of the respiratory tract, and respiratory state: unbridled ventilation
  • • Demonstrates respiratory state: permeability of the respiratory tract, revealed by the following indicators (specify from 1 to 5: severe, substantial, moderate, mild or null deviation of normal values):
  • Respiratory frequency and rhythm
  • Inhalation depth
  • Ability to expel secretions
  • Other examples

    The patient will be able to:

    • • Tower effectively
    • • Effectively expectorate
    • • Keep the airways open
    • • Auscultation: preserved vesicular murmur
    • • Respiratory frequency and rhythm within normal limits
    • • Pulmonary function within normal limits
    • • Describe a home care plan

    NIC Interventions

    • Ventilation assistance: Promote an optimal spontaneous respiratory pattern, which achieves the maximum possible oxygen exchange and carbon dioxide in the lungs
    • Aspiration of the respiratory tract: elimination of secretions from the respiratory tract by inserting an aspiration catheter in the mouth and/or trachea of ??the patient
    • Change of position: place the patient or part of his body in a certain way to promote physiological and psychological well -being
    • Tos promotion: Promote that the patient performs deep inhalations to generate high intrathoracic pressures and compress the underlying pulmonary parenchyma, thus managing to expel the air with force
    • Management of respiratory tract: facilitate the permeability of the respiratory system
    • Asthma management: identification, treatment and prevention of reactions caused by inflammation or constriction of the respiratory system
    • Respiratory monitoring: Patient data collection and analysis to ensure the permeability of the respiratory tract and an appropriate gas exchange
    • Precautions to avoid aspiration: prevention or minimization of risk factors in a patient with possibilities of aspiration

    Nursing Activities

    Valuations

    • • Evaluate and record the following:
      • Effectiveness of oxygen administration and other treatments
      • Effectiveness of prescribed medications
      • Pulsioximetry values ??
      • Evolution of arterial gasometry values, if proceeds
      • Frequency, depth and breathing effort
      • Related factors, such as pain, ineffective cough, viscous mucus and fatigue
    • • Pulmonary auscultation, seeking if there is reduction or absence of ventilation, as well as anomalous noises
    • • (NIC) aspiration of the respiratory tract:
      • Determine the need for oral or tracheal aspiration
      • Monitor patient oxygenation (arterial and venous saturation) and his hemodynamic status (average blood pressure, heart rate) immediately before, during and after aspiration
      • Record the type of aspirated secretions and its amount

    Patient and family education

    • • Instruct in the correct use of auxiliary equipment (oxygen, vacuum cleaner, spratometer, inhalers, breathing with intermittent positive pressure, etc.)
    • • Inform the patient and the family that is prohibited smoking in the room; Teach the importance of quitting smoking
    • • Teach the patient effectively coughing and deep breathing techniques to facilitate the elimination of secretions
    • • Teach the patient to immobilize the surgical wound when coughing
    • • Teach the patient and family the meaning of certain changes in expectoration, such as color, characteristics, quantity and smell
    • • (NIC) aspiration of the respiratory tract: teach the patient and/or family to aspire the respiratory tract, as required

    Collaboration activities

    • • Consult the respiratory physiotherapy expert, if necessary
    • • Consult the doctor about the need for percussion or accessory equipment
    • • Administer humidified air and oxygen according to the protocols of the institution
    • • Manage or help with aerosols, ultrasound nebulizer and other pulmonary treatments, according to the policies and protocols of the institution
    • • Notify the doctor if blood gases are abnormal

    Others

    • • Encourage the patient to perform physical activity to favor the elimination of secretions
    • • Promote the use of the encouraged spirometer (Smith-Sims, 2001)
    • • If the patient is not able to walk, change it from the right side to left (and vice versa) at least every two hours
    • • Inform the patient before performing procedures, to reduce anxiety and increase the feeling of control
    • • Provide emotional support (such as assuring the patient that the cough will not make “the points”)
    • • Place the patient so that the maximum expansion of the thorax is achieved (for example, with the head of the high bed 45 ° unless it is contraindicated [Collard et al., 2003; Drakulovic et a i, 1999])
    • • Aspirate through nasopharynx and oropharynx to eliminate secretions (specify frequency)
    • • Perform endotracheal or nasotracheal aspiration, as required (hyperoxigenar with ambu-bag before and after aspiring by the endotracheal tube or through tracheostomy)
    • • Maintain adequate hydration to reduce the viscosity of secretions
    • • Eliminate or treat causal factors such as pain, fatigue and thick secretions

    At home

    • • Teach the patient and family the home care plan (medicines, hydration, nebulization, devices, postural drainage, signs and symptoms of complications, community resources, etc.)
    • • Evaluate at home the possible existence of some factors, such as allergens, which could precipitate the ineffective cleaning of the respiratory tract
    • • Help the patient and their family identify ways to avoid allergens, including exposure to tobacco smoke

    Babies and Children

    • • Insist parents in which it is important that the child has, and that the cough should not always be suppressed with medications
    • • Weigh the need to clean the respiratory tract with the need to avoid fatigue produced by cough, when it is persistent or a dyspnea symptom
    • • Let the child take the stethoscope and listen to their own respiratory noises