Plan of Care for: CP

Ineffective Airway clearance Defining Characteristics Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed Related Factors (r/t)
Environmental

Second-hand smoke; smoke inhalation; smoking

Obstructed Airway

Airway spasm; excessive mucus; exudate in the alveoli; foreign body in airway; presence of artificial airway; retained secretions; secretions in the bronchi
Physiological

Allergic airways; asthma; COPD; hyperplasia of the bronchial walls; infection; neuromuscular dysfunction
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Outcomes

Aspiration Prevention; Respiratory Status: Airway Patency, Gas Exchange, Ventilation

Client Outcomes
Client Will (Specify Time Frame):

Demonstrate effective coughing and clear breath sounds Maintain a patent airway at all times Explain methods useful to enhance secretion removal Explain the significance of changes in sputum to include color, character, amount, and odor Identify and avoid specific factors that inhibit effective airway clearance

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Interventions

Airway Management, Airway Suctioning, Cough Enhancement

Nursing Interventions and Rationales

Auscultate breath sounds q 1 to 4 hours. Breath sounds are normally clear or

scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction (Fauci et al, 2008). Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16 (Bickley & Szilagyi, 2009). With secretions in the airway, the respiratory rate will increase. Monitor blood gas values and pulse oxygen saturation levels as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 (normal: 80 to 100) indicates significant oxygenation problems (Clark, Giuliano, & Chen, 2006). Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia (Wong & Elliott, 2009).

Position the client to optimize respiration (e.g., head of bed elevated 30-45 degrees and repositioned at least every 2 hours). An upright position allows for
maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. EB: In a mechanically ventilated client, there is a decreased incidence of pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position (Seckel, 2006).

Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles. This technique
can help increase sputum clearance and decrease cough spasms (Donahue, 2002). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

If the client has obstructive lung disease, such as COPD, cystic fibrosis, or bronchiectasis, consider helping the client use the forced expiratory technique, the huff cough. The client does a series of coughs while saying the word huff. This technique prevents the glottis from closing during the cough and is effective in
clearing secretions (van der Schans, 2007; Bhowmik et al, 2009).

Encourage the client to use an incentive spirometer if ordered. Recognize that controlled coughing and deep breathing may be just as effective. EB: A study of
postoperative abdominal surgery clients demonstrated that coughing and deep breathing clients versus use of an incentive spirometer resulted in no significant difference in oxygenation (Genc, Yildirim, & Gnerli, 2004). A Cochrane review found that use of incentive spirometry was not more effective than positive pressure breathing techniques (Freitas et al, 2007).

Encourage activity and ambulation as tolerated. If unable to ambulate the client, turn the client from side to side at least every 2 hours. Body movement
helps mobilize secretions. EB: Changes of postoperative position from sitting to standing are very important to improve outcomes, and the supine position should be avoided (Nielsen, Holte, & Kehlet, 2003). See interventions for Impaired Gas exchange for further

information on positioning a respiratory client. Encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move
secretions.

Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, or inflamed pharynx with inhaled steroids.Bronchodilators
decrease airway resistance, improve the efficiency of respiratory movements, improve exercise tolerance, and can reduce symptoms of dyspnea on exertion (Barnett, 2008). Provide postural drainage, percussion, and vibration as ordered. EB: A Cochrane review of studies demonstrated that there is no advantage of chest physiotherapy over other airway clearance techniques for cystic fibrosis clients (Main, Prasad, & Schans, 2005). Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

Critical Care Pediatric

Educate parents about the risk factors for ineffective airway clearance such as foreign body ingestion and passive smoke exposure. EB: Studies indicate the most
common types of pediatric foreign bodies include vegetables, nuts, small toys, and other pieces of food (Midulla, Guidi, & Barbato, 2005). See the care plan Risk for Suffocation for more interventions on choking. EB: Passive smoke exposure significantly increases the risk of respiratory infections in children (Chatzimicael et al, 2008).

Educate children and parents on the importance of adherence to peak expiratory flow (PEF) monitoring for asthma self-management. EBN: Children
adherent to at least once-daily PEF monitoring were less likely to have an asthma episode than those who were less adherent (Burkhart, Rayens, & Revelette, 2007).

Educate parents and other caregivers that cough and cold medication bought over the counter are not safe for a child under 2 unless specifically ordered by a health care provider. Over the counter cold and cough medications are no longer
recommended for children under the age of 2 unless recommended by a health care provider. Minimal data exist to support their effectiveness, and overuse can cause harm (Ky et al, 2006; Woo, 2008).

Geriatric Home Care

Some of the above interventions may be adapted for home care use. Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems, assistive devices, and community or home health services. Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, poor air flow, stressful family relationships).EBN: Home environmental triggers of asthma
have been found to include dust/dust mites, animal dander, mold, perfumes/detergents, and cigarette smoke. Psychosocial triggers included family tensions, physical activity, anxiety/stress, and friends/peer pressure (Navaie-Waliser et al, 2004). Assess affective climate within family and family support system. Problems with respiratory function and resulting anxiety can provoke anger and frustration in the client.

Feelings may be displaced onto caregiver and require intervention to ensure continued caregiver support. Refer to care plan for Caregiver role strain.

Refer to GOLD and ACP-ASIM/ACCP guidelines for management of home care and indications of hospital admission criteria (Chojnowski, 2003). When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family
members assuming responsibility for respiratory monitoring often find this stressful. They may not have been able to assimilate fully any instructions provided by hospital staff.

When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments. Provide family with support for care of a client with chronic or terminal illness. Breathing difficulty can provoke extreme anxiety, which can interfere with the client's
ability or willingness to adhere to the treatment plan. Refer to care plan for Anxiety. Witnessing breathing difficulties and facing concerns of dealing with chronic or terminal illness can create fear in caregiver. Fear inhibits effective coping. EBN: Parents of a child with cystic fibrosis particularly benefit from nursing support. Parents deal with devastation upon receiving the diagnosis, a sense of fear and isolation, an overwhelming sense of guilt and powerlessness, vigilance, and returning to normalcy (Carpenter & Narsavage, 2004). Refer to care plan for Powerlessness.

Instruct the client to avoid exposure to persons with upper respiratory infections, to avoid crowds of people, and wash hands after each exposure to groups of people, or public places. Determine client adherence to medical regimen. Instruct the client and family in importance of reporting effectiveness of current medications to physician. Inappropriate use of medications (too much or too little) can influence amount of
respiratory secretions.

Teach the client when and how to use inhalant or nebulizer treatments at home. Teach the client/family importance of maintaining regimen and having PRN drugs easily accessible at all times. Success in avoiding emergency or institutional
care may rest solely on medication compliance or availability. EBN: Parents/family have been found to have inadequate knowledge about recognition of asthma attacks, triggers, and management (Navaie-Waliser et al, 2004).

Instruct the client and family in the importance of maintaining proper nutrition, adequate fluids, rest, and behavioral pacing for energy conservation and rehabilitation. Instruct in use of dietary supplements as indicated. Illness may suppress appetite,
leading to inadequate nutrition. Supplements will allow clients to eat with minimal energy consumption. Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life-threatening. Refer for home health aide services for assistance with ADLs. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

Assess family for role changes and coping skills. Refer to medical social services as necessary. Clients with decreased oxygenation are unable to maintain role
activities and therefore experience frustration and anger, which may pose a threat to family integrity. Family counseling to adapt to role changes may be needed.

For the client dying at home with a terminal illness, if the death rattle is present with gurgling, rattling, or crackling sounds in the airway with each breath, recognize that anticholinergic medications can often help control symptoms, if given early in the process. Anticholinergic medications can help decrease the
accumulation of secretions, but do not decrease existing secretions. This medication must be administered early in the process to be effective (Hipp & Letizia, 2009).

For the client with a death rattle, nursing care includes turning to mobilize secretions, keeping the head of the bed elevated for postural drainage of secretions, and avoiding suctioning. Suctioning is a distressing and painful event for
clients and families, and is rarely effective in decreasing the death rattle (Hipp & Letizia, 2009).

Client/Family Teaching and Discharge Planning

Teach the importance of not smoking. Refer to a smoking cessation program, and encourage clients who relapse to keep trying to quit. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider. EB: A systemic review of research demonstrated that the
combination of medications and an intensive, prolonged counseling program supporting smoking cessation were effective in promoting long-term abstinence from smoking (Fiore et al, 2008). A Cochrane review found that use of the medication varenicline (Chantix) increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Cahill, Stead, & Lancaster, 2008).

Teach the client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open (Bhowmik et al, 2009). EB: A study demonstrated that use of the mucus clearance device
had improved exercise performance compared with COPD clients who use a sham device (Wolkove et al, 2004). A Cochrane review found that there was no clear evidence that oscillation was more or less effective than other forms of physiotherapy for airway clearance in cystic fibrosis (Morrison & Agnew, 2009).

Teach the client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids as ordered following precautions to decrease side effects. Teach the client how to deep breathe and cough effectively. EB: Controlled
coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Bellone et al, 2000).

Teach the client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to secondhand smoke. Educate the client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor. With this knowledge,
the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

Teach the client/family need to take ordered antibiotics until the prescription has run out. Taking the entire course of antibiotics helps to eradicate bacterial infection,
which decreases lingering, chronic infection.

Teach the family of the dying client in hospice with a death rattle, that rarely are clients aware of the fluid that has accumulated, and help them find evidence of comfort in the client's nonverbal behavior (Hipp & Letizia, 2009).

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