Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00031
Nanda label: Ineffective airway clearance
Diagnostic focus: Airway clearance
Nursing diagnosis for ineffective airway clearance is used to describe a condition where the body does not clear the airways of accumulated secretions. Patients with this diagnosis typically suffer from symptoms such as excessive coughing and difficulty breathing. The condition may be caused by a variety of factors, including smoking, exposure to irritants, structural abnormalities of the airways, infections, insufficient hydration, and other underlying medical conditions. To assess and treat this condition, it is important to understand the defining characteristics, possible related factors, at risk populations, and suggested interventions.
NANDA Nursing Diagnosis Definition
The official NANDA International (NI) nursing diagnosis definition for ineffective airway clearance is “inability to expectorate, clear, or maintain patent airways by coughing or any other means”. The diagnosis can be further divided into three subtypes: acute, chronic, or recurrent.
Defining Characteristics List
Subjectives:
- Chest tightness
- Wheezing
- Coughing
- Difficult or labored breathing
- Secretion accumulation
- Dyspnea
Objectives:
- Slow or ineffective coughing
- Significant amount of retained secretions
- Bradycardia
- Tachypnea
- Hypercapnia
- Decreased lung expansion
- Increased respiratory rate
Related Factors
- Excessive smoking – Cigarette smoke impairs mucociliary clearance and contributes to airway blockage and decreased ability to clear secretions.
- Irritant exposure – Airway irritation can impede effective coughing and cause dysfunction of the cilia cells and mucus glands.
- Structural abnormalities such as nasal polyps, asthma, cystic fibrosis, and chronic obstructive pulmonary disease (COPD) can narrow the airways, reducing their ability to effectively contract and expel secretions.
- Infection – Pathogenic microorganisms cause inflammation of the airways and increase mucus production.
- Inadequate hydration – Fluids thin out thick secretions, making them easier to clear.
- Underlying medical conditions such as obesity, stroke, or neuromuscular disease can lead to reduced respiratory muscle strength, which can make it harder to clear secretions.
At-Risk Population
- Elderly – Older adults are more susceptible to infection due to reduced immunity and age-related changes in the lungs, increasing their risk of ineffective airway clearance.
- Chronically Ill – People with chronic illnesses such as diabetes and heart failure are more likely to develop airway obstruction due to altered breathing patterns and poor management of the illness.
- Children – Children have smaller, less developed airways and are prone to viral illnesses, both of which can increase the risk of ineffective airway clearance.
- Smokers – Nicotine and other toxins present in cigarette smoke damage the cilia and reduce epithelial secretion, impairing the body’s ability to clear secretions.
Associated Conditions
- Bronchiectasis
- Chronic Bronchitis
- Pulmonary edema
- Respiratory tract infection
- Acute Respiratory Distress Syndrome (ARDS)
- Pulmonary embolism
Suggestions of Use
Nursing diagnoses of ineffective airway clearance should be used when assessing, planning, and evaluating the care of patients with difficulty clearing secretions. This diagnosis can also be used to screen patients for potential risk factors, plan interventions, and evaluate outcomes related to airway clearance.
Suggested Alternative NANDA Nursing Diagnoses
- Activity Intolerance
- Impaired Gas Exchange
- Risk for Deficient Fluid Volume
- Impaired Spontaneous Ventilation
- Risk for Respiratory Complications
- Risk for Aspiration
Usage Tips
When assigning the nursing diagnosis of ineffective airway clearance, consider factors such as the severity of the condition, long-term effects on the patient, and the client’s ability to adapt to the situation. Also consider the use of alternative nursing diagnoses, particularly if a long-term treatment plan is needed.
NOC Outcomes
- Cough Effectiveness
- Circulation Status
- Sputum Production
- Ventilation Pattern
- Gas Exchange
Explanation
- Cough Effectiveness – Cough effectiveness is measured by how well a patient can produce and clear secretions from the airways.
- Circulation Status – This outcome evaluates the patient’s cardiac output, heart rate, and blood pressure.
- Sputum Production – This outcome assesses how much and what type of sputum the patient produces.
- Ventilation Pattern – This outcome measures the rate and volume of air being inhaled and exhaled, as well as the presence of excessive respiratory effort.
- Gas Exchange – This outcome measures the balance of oxygen and carbon dioxide levels in the blood.
Evaluation Objectives and Criteria
When evaluating the effectiveness of nursing interventions, consider the following objectives and criteria:
- Increased cough effectiveness
- Improved circulation status
- Increased sputum production
- Improved ventilation pattern
- Improved gas exchange
NIC Interventions
- Incentive Spirometry
- Airway Suctioning
- Chest Physiotherapy
- Vaporizers
- Postural Drainage and Chest Percussion
- Oxygen Therapy
- Tracheostomy Care
Explanation
- • Incentive Spirometry – This intervention helps to improve ventilation and mucociliary clearance by encouraging deep breathing through a device that measures airflow.
- • Airway Suctioning – This intervention involves insertion of a tube into the airway to remove excess mucus and secretions.
- • Chest Physiotherapy – This involves using vibration, percussion, and percussion-assisted coughing to help break up secretions and expel it.
- • Vaporizers – These devices provide warm, humidified air to moisten mucosal membranes, loosen secretions, and reduce bronchospasm.
- • Postural Drainage & Chest Percussion – This intervention involves positioning the patient in a way that drains secretions from the lungs, followed by the rhythmic clapping over the chest to help move secretions into the airway.
- • Oxygen Therapy – This may include supplemental oxygen therapy or nonrebreather masks to improve oxygen saturation levels.
- • Tracheostomy Care – This includes cleaning the tracheostomy tube, changing/replacing tubes, suctioning, and administering topical or systemic medications.
Nursing Activities
Nurses can implement a variety of activities to help manage and prevent ineffective airway clearance:
- Monitor vital signs to assess cardiac output and detect changes in respiratory rate and pattern.
- Encourage the patient to practice deep breathing and coughing techniques.
- Monitor the patient’s response to pharmacologic agents and document changes in secretions.
- Assist the patient in changing positions, as needed, to reduce airway obstruction.
- Assess for areas of infection or irritation and keep them clean and dry.
- Educate patients about proper hydration and the importance of an adequate diet.
- Instruct patients to avoid exposure to irritants and instruct smokers to quit.
- Administer medications, motivate, and assist the patient with incentive spirometry.
Conclusion
Nursing diagnosis of ineffective airway clearance is used to describe a condition where the body does not clear the airways of accumulated secretions. Understanding the causes, related factors, and associated conditions can help identify patients at risk and guide the development of a comprehensive treatment plan. Nurses play a critical role in the management of this diagnosis, implementing a variety of interventions and activities to help diagnose, prevent, and treat the condition.
FAQs
- Q1. What is the definition of NANDA nursing diagnosis for ineffective airway clearance?
A1. The official NANDA International (NI) nursing diagnosis definition for ineffective airway clearance is “inability to expectorate, clear, or maintain patent airways by coughing or any other means”. The diagnosis can be further divided into three subtypes: acute, chronic, or recurrent. - Q2. How can nurses assess and treat patients with this diagnosis?
A2. When assessing and treating this condition, it is important to understand the defining characteristics, related factors, at-risk population, and suggested interventions. Nurses can implement a variety of activities to help manage and prevent ineffective airway clearance, such as monitoring vital signs, educating patients, administering medications, and assisting the patient with incentive spirometry. - Q3. What are some of the associated conditions with this diagnosis?
A3. Some of the associated conditions with ineffective airway clearance include bronchiectasis, chronic bronchitis, pulmonary edema, respiratory tract infection, acute respiratory distress syndrome (ARDS), and pulmonary embolism. - Q4. What are some of the suggested interventions for this diagnosis?
A4. Suggested interventions for this diagnosis include incentive spirometry, airway suctioning, chest physiotherapy, vaporizers, postural drainage and chest percussion, oxygen therapy, and tracheostomy care. - Q5. What are some of the evaluation objectives and criteria for this diagnosis?
A5. When evaluating the effectiveness of nursing interventions for ineffective airway clearance, consider the following evaluation objectives and criteria: increased cough effectiveness, improved circulation status, increased sputum production, improved ventilation pattern, and improved gas exchange.