Ineffective Airway clearance

ADS
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics:
  • Dyspnea; 
  • diminished breath sounds; 
  • orthopnea; 
  • adventitious breath sounds (crackles, wheezes); 
  • cough, ineffective or absent; 
  • sputum production; 
  • cyanosis; 
  • difficulty vocalizing; 
  • wide-eyed; 
  • changes in respiratory rate and rhythm; 
  • restlessness

Related Factors:

Environmental
  • Smoking; 
  • smoke inhalation; 
  • second-hand smoke
Obstructed Airway
  • Airway spasm; 
  • retained secretions; 
  • excessive mucus; 
  • presence of artificial airway; 
  • foreign body in airway; 
  • secretions in bronchi; 
  • exudate in alveoli
Physiological
  • Neuromuscular dysfunction; 
  • hyperplasia of bronchial walls; 
  • chronic obstructive pulmonary disease; 
  • infection; 
  • asthma; 
  • allergic airways
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Respiratory Status: Ventilation
  • Respiratory Status: Airway Patency
  • Respiratory Status: Gas Exchange
  • Aspiration Control
Client Outcomes
  • Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea
  • Maintains a patent airway at all times
  • Relates methods to enhance secretion removal
  • Relates the significance of changes in sputum to include color, character, amount, and odor
  • Identifies and avoids specific factors that inhibit effective airway clearance
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Airway Management
  • Airway Suctioning
  • Cough Enhancement

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