Monday, November 7, 2011

Ineffective Airway Clearance NIC NOC

Ineffective Airway Clearance

Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Ineffective airway clearance related to
  • The accumulation of secretions
  • Airway spasm
Data:
  • Cough
  • Discharge
  • Dyspneu
  • Cyanosis
  • Respiratory rate increased
  • Ronkhi
  • Wheezing

a. Airway Management:
  • Open the airway with headtilt, chinlift, jaw thrust
  • Set the position to maximize ventilation
  • Use tools airway
  • Perform chest physiotherapy
  • Teach breath deeply and cough effectively
  • Perform suction
  • Auscultation of breath sounds
  • Give bronchodilators (Collaboration)

b. Oxygenation therapy
  • Provide humidification system of oxygen equipment
  • Monitor the flow of oxygen and the amount given
  • Monitor signs of oxygen toxicity
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