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Nursing Care Plan for Ineffective Airway Clearance

Definition: The state in which an individual is unable to clear obstructions or secretions from the respiratory tract to maintain airway patency

Defining Characteristics

  • Abnormal breath sounds (displaced normal sounds, adventitious sounds, diminished or absent sounds)
  • Ineffective cough with or without sputum
  • Tachypnea, dyspnea
  • Verbal reports of inability to clear airway

Desired Outcome

  • Cough produces thin mucus
  • Lungs are clear to auscultation
  • Respiratory rate, depth, and rhythm return to baseline

Nursing Interventions and Rationale

  1. Assess sputum for color, consistency, and amount.
  2. Assess for clinical manifestations of pneumonia.
  3. Provide for maximal thoracic expansion by repositioning, deep breathing, splinting, and pain management to avoid hypoventilation and atelectasis.
  4. Maintain adequate hydration by administering oral and intravenous fluids (as ordered) to thin secretions and facilitate airway clearance.
  5. Provide humidification to airways via oxygen delivery device or artificial airway to thin secretions and facilitate airway clearance.
  6. Administer bland aerosol every 4 hours to facilitate expectoration of sputum. 
  7. Collaborate with the physician regarding the administration of the following:
    1. Bronchodilators to treat or prevent bronchospasms and facilitate expectoration of mucus
    2. Mucolytics and expectorants to enhance mobilization and removal of secretions
    3. Antibiotics to treat infection
  8. Assist with directed coughing exercises to facilitate expectoration of secretions. If patients are unable to perform cascade cough, consider using huff cough (patients with hyperactive airways), end-expiratory cough (patients with secretions in distal airways), or augmented cough (patients with weakened abdominal muscles).
    1. Cascade cough — Instruct patients to do the following:
      1. Take a deep breath and hold it for 1 to 3 seconds
      2. Cough out forcefully several times until all air is exhaled
      3. Inhale slowly through the nose
      4. Repeat once
      5. Rest and then repeat as necessary
    2. Huff cough — Instruct patients to do the folowwing:
      1. Take a deep breath and hold it for 1 to 3 seconds
      2. Say the word “huff” while coughing out several times until air is exhaled
      3. Inhale slowly through the nose
      4. Repeat as necessary
    3. End-expiratory cough — Instruct patients to do the following:
      1. Take a deep breath and hold it for 1 to 3 seconds
      2. Exhale slowly
      3. At the end of exhalation, cough once
      4. Inhale slowly through the nose
      5. Repeat as necessary or follow with cascade cough
    4. Augmented cough — Instruct patients to do the following:
      1. Take a deep breath and hold it for 1 to 3 seconds
      2. Perform one or more of the following maneuvers to increase intraabdominal pressure:
        1. Tighten knees and buttocks
        2. Bend forward at the waist
        3. Place a hand flat on the upper abdomen just under the xiphoid process and press in and up abruptly during coughing
        4. Keep hands on the chest wall and press inward with each cough
        5. Inhale slowly through the nose
        6. Rest and repeat as necessary
  9. Suction nasotracheally or endotracheally as necessary to assist with secretion removal. 
  10. Reposition patients at elast every 2 hours or use continuous lateral rotation therapy to mobilize and prevent stasis of secretions.
  11. Consider chest physiotherapy (postural drainage and/or chest percussion) three to four times per day in patients with large amounts of sputum to assist with the expulsion of retained secretions. 
  12. Allow rest periods between coughing sessions, chest physiotherapy, suctioning, or any other demanding activities to promote energy vonservation.