00031 Ineffective airway clearance

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00031 Ineffective airway clearance

Definition of the NANDA label

Inability to clear secretions or obstructions from the respiratory tract to keep the airways clear.

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Defining characteristics

  • Decrease in respiratory sounds.
  • Changes in respiratory rate and rhythm.
  • Dyspnea and orthopnea.
  • Added respiratory noises (rales, rhonchi, crackles and wheezing).
  • Absent or unproductive cough.
  • Agitation.
  • Difficulty vocalizing.
  • Cyanosis.
  • Production of sputum.

Related factors

Environmental

  • Smoking and passive smoking.
  • Irritation from smoke.

Physiological

  • Asthma and allergic airways.
  • Neuromuscular dysfunction.
  • Respiratory infection.
  • Hyperplasia of the bronchial walls.
  • Chronic obstructive pulmonary disease (COPD).

Mechanical (airway obstruction)

  • Retention of secretions.
  • Foreign bodies in the airways.
  • Spasm of the airways.
  • Excessive mucus.
  • Bronchial secretions.
  • Presence of an artificial airway.
  • Alveolar exudate.

Associated condition

  • Airway spasm
  • Allergic airway
  • Asthma
  • Chronic obstructive pulmonary disease
  • Exudate in the alveoli
  • Hyperplasia of the bronchial walls
  • Infection
  • Neuromuscular impairment
  • Presence of artificial airway

NOC

  • Permeability of the airways.
  • Suction control.
  • Ventilation.
  • Gas exchange.

NIC

  • Airway management.
  • Improve cough.
  • Respiratory monitoring.
  • Respiratory physiotherapy.
  • Helps with ventilation.
  • Aspiration of the airways.
  • Change of position.
  • Precautions to avoid aspiration.
  • Acid-base monitoring.
  • Oxygen therapy.

This diagnosis will retire from the NANDA-I Taxonomy in the 2021-2023 edition unless additional work is completed to bring it up to a level of evidence 2.1 or higher.

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