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NCLEX & CGFNS Practice Questions
Ineffective Airway Clearance
  • Actual
  • Risk for (Potential)

Related To: [Check those that apply]

  • Decreased energy and fatigue
  • Ineffective cough
  • Tracheobronchial infection
  • Tracheobronchial obstruction (including foreign body aspiration)
  • Copious tracheobronchial secretions
  • Perceptual/cognitive impairment
  • Impaired respiratory muscle function
  • Trauma

As evidenced by: [Check those that apply]

  • Abnormal breath sounds (crackles, rhonchi, wheezes)
  • Changes in respiratory rate or depth
  • Cough
  • Hypoxemia/cyanosis
  • Dyspnoea
  • Chest wheezing

Patient’s Diagnosis: –
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Objective/Expected Outcome;The patient will:

  • Maintain airway free of secretions.
  • Others

Note: you need to indicate time frame/target as objective must be measurable.

Nursing Interventions Scientific Rationale
Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.
Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnoea on exertion, evidence of splinting, use of accessory muscles, position for breathing. Abnormality indicates respiratory compromise.
Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough: respiratory muscle fatigue, severe bronchospasm, thick tenacious secretions, and others.
Note presence of sputum; assess quality, colour, amount, odour, and consistency. May be a result of infection, bronchitis, chronic smoking, and others. A sign of infection is discoloured sputum (no longer clear or white); an odour may be present.
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.
Assist patient in performing coughing and breathing manoeuvres. To improve productivity of the cough.
Encourage oral intake of fluids within the limits of cardiac reserve. To prevent drying of secretions.
Demonstrate and teach coughing, deep breathing, and splinting techniques. So patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.

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