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DefinitionIneffective Airway Clearance Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
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, exudates in alveoli, Physiological, Neuromuscular dysfunction, hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways
Nursing Outcomes
- Respiratory Status: Ventilation
- Respiratory Status: Airway Patency
- Respiratory Status: Gas Exchange
- Aspiration Control
- 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
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