Ineffective Airway Clearance Nursing Care Plans Diagnosis and Interventions
Ineffective Airway Clearance NCLEX Review and Nursing Care Plans
Ineffective airway clearance occurs when the body loses the ability to maintain a patent airway.
The human body has several mechanisms to keep the airway free from occlusions such as the presence of microorganisms in the airway, the presence of small hair in the nostrils, and the ability to cough to clear out obstructions.
In instances that these mechanisms are impaired, a risk for a compromised airway arise.
A compromised airway can lead to a series of serious problems including death. Immediate attention and intervention are necessary to address airway problems.
It is also important to acknowledge the signs and symptoms associated with a compromised airway such as the following:
- Abnormal breath sounds (e.g. crackles, wheezes, rhonchi)
- Abnormal respiration (rate, rhythm, and depth)
- Dyspnea or difficulty breathing
- Excessive secretions
- Hypoxia / cyanosis
- Ineffective or absent cough
- Orthopnea
Ineffective Airway Clearance Nursing Diagnosis
Nursing Care Plan for Ineffective Airway Clearance 1
Cerebrovascular Accident (CVA or Stroke)
Nursing Diagnosis: Ineffective airway clearance related to neuromuscular involvement secondary to CVA infarct as evidenced by the presence of abnormal breath sounds and dyspnea
Desired Outcome: The patient will learn and develop techniques to maintain an open and clear airway.
| Nursing Interventions for Ineffective Airway Clearance | Rationale |
| Assess airway patency. | Maintaining an open and clear airway is vital to retain airway clearance. |
| Auscultate breath sounds. | Abnormal breath sounds such as crackles, stridor, and wheezes can signify ineffective airway clearance. Baseline information will help measure the progress and success of treatment. |
| Assess the patient’s ability to cough out secretions. | Stroke can cause neuromuscular weakness and may limit the patient’s ability to secrete mucus and clear the airway. |
| Refer the patient for chest physiotherapy. | A chest physiotherapist can help support the patient in maintaining a clear airway. They can also teach breathing exercises to promote the secretion of mucus. |
| Refer the patient for speech and language therapy. | Stroke can diminish or reduce the patient’s ability to swallow. The patient can choke and cause further airway problems. |
| Refer the patient for physiotherapy and occupational therapy. | Both the physiotherapist and occupational therapist can help the patient cope with mobility issues. They can identify the needs for mobility aids and devices. |
| Educate patient on the following (or reinforce the techniques taught by the chest physiotherapist): Proper positioning to straighten airway Use of abdominal muscles to effectively cough The use of incentive spirometry Importance of frequent position changes | Those techniques assist in the proper drainage and secretion of mucus to prevent it from occluding the airway. |
| Educate patient on other ways to clear airway such as maintaining proper hydration status, proper use of medications to promote a clear airway, and avoiding cigarette smoking if known smoker. | The patient needs to understand different techniques to promote airway clearance and prevent the build-up of mucus in the airways and lungs. |
Nursing Care Plan for Ineffective Airway Clearance 2
Tracheostomy
Nursing Diagnosis: Ineffective airway clearance related to copious secretions secondary to tracheostomy as evidenced by tachypnea, difficulty of breathing, and very thick mucus secretions
Desired Outcome: The patient will learn coughing techniques to clear mucus and maintain an open airway.
| Nursing Interventions for Ineffective Airway Clearance | Rationale |
| Assess vital signs. | The patient’s vital signs can signify changes in breathing status and oxygenation. |
| Assess the patient’s ability to cough out secretions. | The ability to effectively cough helps in regaining the ability to breathe without the help of a tracheostomy. Also, assessing the patient’s ability to effectively cough out secretions will help establish care needs and direct care plan. |
| Suction secretions if the patient is unable to cough it out effectively. | The patient may not be ready to perform effective coughing. In this case, suctioning of the copious secretion is necessary to promote a clear airway. |
| Educate the patient on effective coughing techniques and breathing exercises. | Educating the patient on breathing exercises can help promote independence to maintain a clear airway without the help of suction machines. |
| Refer the patient for chest physiotherapy. | A chest physiotherapist can help in the assessment of the patient’s ability to independently clear airways. They can also educate the patient on breathing exercises and effective coughing techniques. |
Nursing Care Plan for Ineffective Airway Clearance 3
Foreign Body Obstruction
Nursing Diagnosis: Ineffective airway clearance related to foreign body obstruction of the airway as evidenced by anxiety, nasal flaring, intercostal retractions, and use of accessory muscles when breathing
Desired Outcome: The patient will maintain a clear, open airway as evidenced by a normal breathing pattern.
| Nursing Interventions for Ineffective Airway Clearance | Rationale |
| Assess oxygenation status. | Foreign body obstruction can be serious and severely cut of air exchange. |
| Assess the cause and severity of the obstruction. | Information regarding the cause of obstruction can help direct medical management. |
| Encourage the patient to relax. | Anxieties and tension can further constrict the airway and make breathing worse. |
| Perform Heimlich maneuver, abdominal thrusts, or back blows as appropriate. For infants and children, attempt finger sweep method. | These techniques will help dislodge the object out of the airway. |
| Refer the patient to ENT team as required. | Some obstruction may require specialist intervention. |
| Prepare suction machine in the patient’s bedside. | The patient may not be able to cough out the foreign body and build up of secretions. Suctioning will prevent the worsening of obstruction. |
Nursing Care Plan for Ineffective Airway Clearance 4
Chronic Obstructive Pulmonary Disease (COPD)
Ineffective Airway Clearance related to COPD as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, respiratory rates between 12 to 20 breaths per minutes, oxygen saturation between 88 to 92%, and verbalize ease of breathing.
| Nursing Interventions for Ineffective Airway Clearance | Rationales | |
| Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess breath sounds via auscultation. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Breath sounds are important signs of COPD: wheeze (emphysema), crackles (bronchitis), or absent breath sounds (refractory asthma)Suction secretions. | To help clear thick phlegm that the patient is unable to expectorate. |
| Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. | To increase the oxygen level and achieve an SpO2 value within the target range of 88 to 92%. | |
| Administer the prescribed COPD medications (e.g. bronchodilators, steroids, or combination inhalers / nebulizers) and antibiotic medications. | Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Antibiotics: To treat bacterial infection, which may trigger exacerbation of COPD. | |
| Elevate the head of the bed and assist the patient to assume semi-Fowler’s position. | Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Nursing Care Plan for Ineffective Airway Clearance 5
Pneumonia
Ineffective Airway Clearance related to the disease process of bacterial pneumonia as evidenced by shortness of breath, wheeze, SpO2 level of 85%, productive cough, difficulty to expectorate greenish phlegm
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by being able to expectorate phlegm effectively, have respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96%, and verbalize ease of breathing.
| Nursing Interventions for Ineffective Airway Clearance | Rationales |
| Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. |
| Encourage coughing up of phlegm. Suction secretions as needed. Perform steam inhalation or nebulization as required/ prescribed. | To help clear thick phlegm that the patient is unable to expectorate. |
| Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician. | To increase the oxygen level and achieve an SpO2 value of at least 96%. |
| Administer the prescribed airway medications (e.g. bronchodilators) and antibiotic medications. | Bronchodilators: To dilate or relax the muscles on the airways. Steroids: To reduce the inflammation in the lungs. Antibiotics: To treat bacterial pneumonia. |
| Elevate the head of the bed and assist the patient to assume semi-Fowler’s position. | Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Nursing Care Plan for Ineffective Airway Clearance 6
Pharyngitis
Ineffective Airway Clearance related to inflammation of pharynx as evidenced by difficulty of swallowing and shortness of breath
Desired Outcome: The patient will be able to maintain airway patency and improved airway clearance as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation within the target range (as set by the physician), and verbalize ease of breathing.
| Nursing Interventions for Ineffective Airway Clearance | Rationales |
| Assess the patient’s vital signs and characteristics of respirations at least every 4 hours. Assess for signs of hypoxia. | To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Early signs of hypoxia include irritability, confusion, headache, restlessness, and pallor. |
| Place the patient on a side-lying or prone position. | To promote drainage of saliva from the mouth through gravity, while preventing aspiration, especially in children. |
| Suction secretions. | To help clear thick secretions that the patient is unable to expectorate. |
| Administer the prescribed medications (e.g. corticosteroids) and antibiotic medications. | Steroids: To reduce the edema in the pharynx. Antibiotics: If there is any bacterial infection that is causing the inflammation |
| Elevate the head of the bed and assist the patient to assume semi-Fowler’s position. | Head elevation and proper positioning help improve the expansion of the lungs, enabling the patient to breathe more effectively. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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