Page 3 - Altered Obstructive Nursing Care

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Ineffective Airway Clearance

Related to

• Bronchospasm
• Increased production of secretions; retained secretions; thick, viscous secretions
• Allergic airways
• Hyperplasia of bronchial walls
• Decreased energy/fatigue

Outcomes

• Maintain airway patency with breath sounds clear/clearing.
• Demonstrate behaviors to improve airway clearance, e.g., cough effectively and expectorate
secretions.

Nursing Interventions Rationale

Nursing Assessment

Tachypnea is usually present to some degree
Assess and monitor respirations and breath and may be pronounced on admission or
sounds, noting rate and sounds (tachypnea, during stress or concurrent acute infectious
stridor, crackles, wheezes). Note inspiratory and process. Respirations may be shallow and
expiratory ratio. rapid, with prolonged expiration in
comparison to inspiration.

Some degree of bronchospasm is present
with obstructions in the airway and may or
may not be manifested in adventitious breath
Auscultate breath sounds. Note adventitious sounds such as scattered, moist crackles
breath sounds (wheezes, crackles, rhonchi).
(bronchitis); faint sounds, with expiratory
wheezes (emphysema); or absent breath
sounds (severe asthma).

Respiratory dysfunction is variable
Note presence and degree of dyspnea as for depending on the underlying process such
reports of “air hunger,” restlessness, anxiety,
respiratory distress, use of accessory muscles. as infection, allergic reaction, and the stage
of chronicity in a patient with established
Use 0–10 scale or American Thoracic Society’s COPD. Note: Using a 0–10 scale to rate
“Grade of Breathlessness Scale” to rate breathing
difficulty. Ascertain precipitating factors when dyspnea aids in quantifying and tracking
changes in respiratory distress. Rapid onset
possible. Differentiate acute episode from of acute dyspnea may reflect
exacerbation of chronic dyspnea.
pulmonary embolus.

Identify the occurrence of an infectious
Observe sign and symptoms of infections.
process.

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