NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Respiratory Status: Airway Patency
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Cough Enhancement
* Airway Management
* Airway Suctioning
NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.
* Defining Characteristics: Abnormal breath sounds (crackles, rhonchi, wheezes)
* Changes in respiratory rate or depth
* Chest wheezing
* Related Factors: Decreased energy and fatigue
* Ineffective cough
* Tracheobronchial infection
* Tracheobronchial obstruction (including foreign body aspiration)
* Copious tracheobronchial secretions
* Perceptual/cognitive impairment
* Impaired respiratory muscle function
* Expected Outcomes Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
* Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.
* Auscultate lungs for presence of normal or adventitious breath sounds, as in the following:
o Decreased or absent breath sounds These may indicate presence of mucus plug or other major airway obstruction.
o Wheezing These may indicate increasing airway resistance.
o Coarse sounds These may indicate presence of fluid along larger airways.
* Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. Abnormality indicates respiratory compromise.
* Assess changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be early signs of cerebral hypoxia.
* Assess changes in vital signs and temperature. Tachycardia and hypertension may be related to increased work of breathing. Fever may develop in response to retained secretions/atelectasis.
* Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions).
* Note presence of sputum; assess quality, color, amount, odor, and consistency. This may be a result of infection, bronchitis, chronic smoking, or other condition. A sign of infection is discolored sputum (no longer clear or white); an odor may be present.
Send a sputum specimen for culture and sensitivity as appropriate. Respiratory infections increase the work of breathing; antibiotic treatment is indicated.
* Monitor arterial blood gases (ABGs). Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure.
* Assess for pain. Postoperative pain can result in shallow breathing and an ineffective cough.
* If patient is on mechanical ventilation, monitor for peak airway pressures and airway resistance. Increases in these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation.
* Assess patient’s knowledge of disease process. Patient education will vary depending on the acute or chronic disease state as well as the patient’s cognitive level.
* Assist patient in performing coughing and breathing maneuvers. These improve productivity of the cough.
* Instruct patient in the following:
o Optimal positioning (sitting position)
o Use of pillow or hand splints when coughing
o Use of abdominal muscles for more forceful cough
o Use of quad and huff techniques
o Use of incentive spirometry
o Importance of ambulation and frequent position changes
Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal pressure and upward diaphragmatic movement.
* Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation). These promote better lung expansion and improved air exchange.
* If patient is bedridden, routinely check the patient’s position so he or she does not slide down in bed. This may cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.
* If cough is ineffective, use nasotracheal suctioning as needed:
o Explain procedure to patient.
o Use soft rubber catheters. This prevents trauma to mucous membranes.
o Use curved-tip catheters and head positioning (if not contraindicated). These facilitate secretion removal from a specific side (right versus left lung).
o Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure and use supplemental oxygen as appropriate. This prevents suction-related hypoxia.
o Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient experiences bradycardia, an increase in ventricular ectopy, and/or desaturation.
o Use universal precautions: gloves, goggles, and mask as appropriate. If sputum is purulent, precautions should be instituted before receiving the culture and sensitivity report.
Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of weakness, thick mucus plugs, or excessive mucus production.
* Institute appropriate isolation precautions for positive cultures (e.g., methicillin-resistant Staphylococcus aureus [MRSA] or tuberculosis).
* Use humidity (humidified oxygen or humidifier at bedside). This loosens secretions.
* Encourage oral intake of fluids within the limits of cardiac reserve. Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing.
* Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered, noting effectiveness and side effects.
* For patients with chronic problems with bronchoconstriction, instruct in use of metered-dose inhaler (MDI) or nebulizer as prescribed.
* Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and home care/rehabilitation environments). Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning.
Coordinate optimal time for postural drainage and percussion (i.e., at least 1 hour after eating). This prevents aspiration.
* For patients with reduced energy, pace activities. Maintain planned rest periods. Promote energy-conservation techniques. Fatigue is a contributing factor to ineffective coughing.
* For acute problem, assist with bronchoscopy. This obtains lavage samples for culture and sensitivity, and removes mucus plugs.
* If secretions cannot be cleared, anticipate the need for an artificial airway (intubation). After intubation:
o Institute suctioning of airway as determined by presence of adventitious sounds.
o Use sterile saline instillations during suctioning. This helps facilitate removal of tenacious sputum.
* For patients with complete airway obstruction, institute cardiopulmonary resuscitation (CPR) maneuvers.
Education/Continuity of Care
* Demonstrate and teach coughing, deep breathing, and splinting techniques. Patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.
* Instruct patient on indications for, frequency, and side effects of medications.
* Instruct patient how to use prescribed inhalers, as appropriate.
* In home setting, instruct caregivers regarding cough enhancement techniques and need for humidification.
* Instruct caregivers in suctioning techniques. Provide opportunity for return demonstration. Adapt technique for home setting.
* For patients with debilitating disease being cared for at home (CVA, neuromuscular impairment, and others), instruct caregiver in chest physiotherapy as appropriate. This may also be useful for the patient with bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the inability to adequately clear them.
* Teach patient about environmental factors that can precipitate respiratory problems.
* Explain effects of smoking, including second-hand smoke. Smoking contributes to bronchospasm and increased mucus production in the airways.
* Refer patient and/or significant others to smoking-cessation group, as appropriate, and discuss potential use of smoking-cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to wean off the effects of nicotine.
* Instruct patient on warning signs of pending or recurring pulmonary problems.
* Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated.