Nurse's Pocket Guide

ineffective AIRWAY CLEARANCE
Desired Outcomes/Evaluation
Criteria—Client Will:
• Maintain airway patency.
• Expectorate/clear secretions readily.
• Demonstrate absence/reduction of congestion with breath
sounds clear, respirations noiseless, improved oxygen exchange
(e.g., absence of cyanosis, ABG/pulse oximetry results within
client norms).
• Verbalize understanding of cause(s) and therapeutic management
regimen.
• Demonstrate behaviors to improve or maintain clear airway.
• Identify potential complications and how to initiate appropriate
preventive or corrective actions.
Actions/Interventions
NURSING PRIORITY NO.1.To maintain adequate, patent airway:
• Identify client populations at risk. Persons with impaired ciliary
function (e.g., cystic fibrosis); those with excessive or
abnormal mucus production (e.g., asthma, emphysema,
pneumonia, dehydration, mechanical ventilation); those
with impaired cough function (e.g., neuromuscular
diseases/conditions such as muscular dystrophy, Guillain-
Barre); those with swallowing abnormalities (e.g., stroke,
seizures, coma/sedation, head/neck cancer, facial burns/
trauma/surgery); immobility (e.g., spinal cord injury, developmental
delay, fractures); infant/child feeding difficulties
(e.g., congenital malformations, developmental delays,
abdominal distention) are all at risk for problems with
maintenance of open airways.
• Monitor respirations and breath sounds, noting rate and
sounds (e.g., tachypnea, stridor, crackles, wheezes) indicative
of respiratory distress and/or accumulation of secretions.
• Evaluate client’s cough/gag reflex and swallowing ability to
determine ability to protect own airway.
• Position head appropriate for age/condition to open or maintain
open airway in at-rest or compromised individual.
• Assist with appropriate testing (e.g., pulmonary function/
sleep studies) to identify causative/precipitating factors.
• Suction naso/tracheal/oral prn to clear airway when excessive
or viscous secretions are blocking airway or client is
unable to swallow or cough effectively.
• Elevate head of bed/change position every 2 hours and prn to
take advantage of gravity decreasing pressure on the
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
78 Cultural Collaborative Community/Home Care