Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Maintaining a patent airway is vital to life. link to Head Injury Nursing Diagnosis & Care Plan, link to Risk for Bleeding Nursing Diagnosis & Care Plan, Environmental factors such as smoke, pollution, and pollen, Adventitious breath sounds (i.e., crackles, rhonchi, wheezes), Altered respiratory rate, depth, and rhythm, Past medical history(PMH) reveals a history of tobacco use, The patient will demonstrate effective ways to remove secretions. (See also tracheostomy.) Site Management. It is performed by making an opening through the neck to the trachea and by inserting an indwelling tube, which should be maintained in place to ensure that the airway is patent (Anderson, 1990). Refer to medical social services as necessary. Nursing Diagnosis: Ineffective airway clearance related to copious secretions secondary to tracheostomy as evidenced by tachypnea, difficulty of breathing, and very thick mucus secretions. During Ineffective airway clearance resultant from deficient cough frequently contributes to these abnormalities. Ineffective airway clearance related to inflamed lung tissue, irritation to the respiratory tract and difficulty to expectorate respiratory secretion due to presence of artificial airway; tracheostomy as manifestated by thick yellow tenacious sputum, presence of adventitious breath sounds, decrease SaO2, elevated respiratory rate and increased body temperature. Here are the main medical diagnoses that can cause this: Ineffective Breathing Pattern/Related to: Anxiety and fear Having a clear and effective airway is number one in patient care. The patient will verbalize factors that contribute to hindering a clear airway. Maintaining an open and clear airway is vital to retain airway clearance and reduce the risk for aspiration. Assess airway patency. Possibly evidenced by. Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. This avoids suction-related hypoxia. Stroke can cause neuromuscular weakness and may limit the patient’s ability to clear the airway. The client has a nursing diagnosis of Ineffective Airway Clearance related to retained secretions as evidenced by moist lung sounds, respiratory rate of 28 to 30 breaths per minute, and ineffective cough. The care of this tube is the same as for a tra-cheostomy tube. Ø Ineffective breathing pattern related to presence of tracheostomy tube and difficulty expectorating sputum as evidence by tenacious secretions, ineffective or absent cough reflex. Abstract Ineffective airway clearance occurs when an artificial airway is used because normal mucociliary transport mechanisms are bypassed and impaired. Risk for impaired skin integrity related to tracheostomy incision. The patient will verbalize symptoms that require immediate medical attention. Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold. Tracheostomy. cretions. Nurses must be prepared to plan interventions for various scenarios and emergencies, such as ineffective airway clearance (related to increased secretions secondary to presence of an artificial airway), or the potential for impaired gas exchange secondary to dislodgment of the tracheostomy tube. 4. Tracheobronchial obstruction (foreign body aspiration) Pathophysiologic Related to excessive or thick sec… These clinical manifestations would be early indicators of hypoxia. DATE/ TIME FOCUS DATA, ACTION and RESPONSE February 17, 2021/3:00p m Ineffective airway clearance related to tracheostomy secretions as evidenced by patient has ineffective cough. Tracheostomy, a surgical procedure done to provide an artificial airway, is an important avenue for both clients needing temporary and permanent ventilation assistance. However, if any of these mechanisms are impaired, there is a risk for a compromised airway. Ineffective airway clearance is the inability to maintain a patent airway. The nurse evaluates client outcome and determines the outcome is met when the client demonstrates: Copious secretions Decreased energy and fatigue Presence of artificial airway: tracheostomy Thick secretions. Ineffective airway clearance related to increased tracheobronchial secretions. By continuing to browse this site, you give consent for cookies to be used. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs. Assess the patient’s ability to cough out secretions. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Decreased energy and fatigue 4. Assess breath sounds by auscultation, This can result in complications and slow recovery time. May be related to. Deep suctioning is a sterile procedure. The page you are looking for does not exist. Neuromuscular function 6. airway clearance, ineffective a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as inability by an individual to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Tracheobronchial infection 8. Owned by The Excel Writers Ltd., Academicadept.Com lists more than 10,000 essays, research papers, and assignment covering all major areas of academics! The laryngectomy tube, which is shorter than a tracheostomy tube but has a larger diameter, is the pa-tient’s only airway. Ineffective airway clearance related to difficulty in breathing as evidenced by restlessness and difficulty of vocalizing. Academicadpet: a custom writing service that provides online custom-written papers, such as term papers, research papers, thesis papers, essays, dissertations, and other custom writing services inclusive of research materials for assistance purposes only. People with pneumonia commonly produce rust-colored, puru-lent sputum. Ineffective airway clearance related to inflamed lung tissue, irritation to the respiratory tract and difficulty to expectorate respiratory secretion due to presence of artificial airway; tracheostomy as manifestated by thick yellow tenacious sputum, presence of adventitious breath sounds, decrease SaO2, elevated respiratory rate and increased body temperature. A tracheostomy creates an opening through the neck into the trachea to establish an airway and remove secretions. Copious and tenacious tracheobronchial secretions 3. Suction the patient if indicated. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. These custom papers should be used with proper references. Any condition or organ that affects blood formation or platelet formation and alters coagulation abilities might contribute to a higher risk of bleeding. Assess family for role changes and coping skills. Coughing is the main mechanism for clearing the airway. Ineffective airway clearance can be life threatening. Assess respirations for rate (count for one full minute), depth and ease, presence of tachypnea (specify), dyspnea and if it occurs during sleep or quiet time; note panting, nasal flaring, grunting, retracting, slowing, deep (hyperpnea) or shallow (hypopnea) breathing, stridor on inspiration, head bobbing during sleep (specify frequency). For more details, including how you can amend your preferences, please read our Cookie Policy. Acute ineffective airway clearance occurs in conditions like postoperative recovery, while chronic ineffective airway clearance occurs in conditions like cerebrovascular accident [CVA] or spinal cord injury. Priority number one for B.R. (Difficulty in breathing or also known as dyspnea and difficulty in vocalizing here were caused by obstruction in the respiratory tract. To improve coughing in individuals with tracheostomy, some techniques include mechanical insufflation-exsufflation, manually assisted cough, and breath stacking or lung volume recruitment (LVR). Abnormal breath sounds (crackles, rhonchi) Dyspnea 9. A peak cough flow (PCF) less than 2.7 L/s (160 L/min) is considered abnormal and is associated with ineffective airway clearance. Ø Impaired verbal communication related to use of artificial airway and cuff as evidenced by inability to speak and signs of frustration. Data: Whitish secretions present Presence of ineffective cough. Impaired verbal communication related to use of cuffed artificial airway/tracheostomy tube as evidenced by inability to speak and signs of frustration. An ineffective cough compromises airway clearance and prevents mucus from being expelled. Suppose a tracheostomy is in place, deep suction the patient to remove secretions. The top three nursing diagnoses were ineffective airway clearance, risk for aspiration, and risk for impaired gas exchange. … Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or … Academicadept.Com represents the ultimate source for students struggling to do research for their term papers! • Risk for ineffective airway clearancerelated to postoperative edema • Risk for ineffective breathing pattern related to pain and anxiety • Disturbed body imagerelated to total laryngectomy and pres-ence of tracheostomy stoma • Impaired verbal communication related to total laryngectomy • Pain related to surgical procedure Refer the patient for speech and language therapy (SALT) team. There are several different types of traumatic brain injuries (TBIs), Risk for Bleeding Nursing Diagnosis & Care Plan. Many disease processes and acute situations can affect the airway. Refer for home health aide services for assist with ADLs. Grunted noted while sleeping. Ineffective Airway Clearance. Ineffective Breathing Pattern Nursing Diagnosis & Care Plan, Impaired Physical Mobility Nursing Diagnosis & Care Plan, Head Injury Nursing Diagnosis & Care Plan, Head injury involves trauma to the skull leading to temporary or permanent brain damage. Usually, protective mechanisms such as microscopic organisms or coughing keep the respiratory tract free of obstructions and secretions. When the breathing pattern is ineffective, the body is most likely not getting enough oxygen to the cells. Desired Outcome: The patient will learn coughing techniques to clear mucus and maintain an open airway. Nursing assessment and intervention are the keys to maintaining airway patency in the patient with an artificial airway in place. Here are some factors that may be related to Ineffective Airway Clearance: 1. Director’s Notice on Social Responsibility, As a source for additional understanding of the subject, As a source of ideas / reasoning for your own research (if properly referenced), For proper paraphrasing (see your educational institution’s definition of plagiarism and acceptable paraphrase). We use cookies to give you the best possible experience on our website. Impaired respiratory muscle function 5. Airway spasm/asthma 2. In NAP 4, 70% of the airway incidents in ICU were related to tracheostomy tubes, and these incidents accounted for 60% of the deaths recorded in the audit. Ineffective airway clearance can be an acute or chronic. This tracheostomy allows for air leakage and prevents achieving adequate intrathoracic pressures, thus confounding the effects of muscle weakness and further diminishing the cough. suctioning, create an FDAR charting for this patient. Presence of artificial airway 7. 1 Core knowledge about tracheostomy care is critical to building the skills nurses need to maintain a patent airway. a) Ineffective Airway Clearance (respiratory depression) related to overdose of morphine b) Ineffective Breathing Pattern (hypoventilation) related to overdose of morphine c) Impaired Gas Exchange related to respiratory depression secondary to overdose of morphine 8. Using this service is LEGAL and IS NOT prohibited by any university/college policies. A variety of respiratory therapy treatments may be used to open constricted airways and liquefy secretions. Identifying potential risk allows for the... RNlessons.com is a website dedicated to helping nursing students and registered nurses achieve their career goals! 3. You are allowed to use the original model paper you will receive in the following ways: Thank you very much for respecting our authors’ copyrights. Ineffective Airway Clearance. The UK National Audit Project 4 (NAP4), conducted by the Royal College of Anaesthetists and the Difficult Airway Society, reported on airway complications in the UK over a 12-month period.
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