Nurse lab compiled

Ineffective Airway Clearance: Inability to clear secretions or obstructions

from the respiratory tract to maintain a clear airway.

May be related to

 Bronchospasms.
 Increased pulmonary secretions.
 Ineffective cough.

Possibly evidenced by

 Abnormal arterial blood gasses.

 Adventitious lung sounds (Wheezes, Rhonchi).
 Changes in respiratory rate and rhythm.
 Chest tightness.
 Cough.
 Cyanosis.
 Dyspnea;orthopnea.
 Retained secretions.

Desired Outcomes

 Client will verbalize understanding of cause and therapeutic

management regimen.
 Client will maintain airway patency as evidenced by clear breath
sounds, improved oxygen exchange, normal rate and depth of
respirations, and ability to effectively cough out secretions.

Nursing Interventions Rationale

Assess respiratory rate, depth, and Changes in the respiratory rate and rhythm may indicate an early
rhythm. sign of impending respiratory distress.

Assess for color changes in the Cyanosis indicates low oxygenation and that breathing is
buccal mucosa, lips, and nail beds. ineffective to maintain adequate tissue oxygenation.

Auscultate lungs for adventitious

Wheezes suggest partial obstruction or resistance. While
breath sounds (wheezes and
rhonchi may indicate retained secretions in the lungs.
rhonchi).

Coughing is a natural way to clear the throat and breathing

passage of foreign particles, irritants, and mucus. Severe
Assess the effectiveness of cough.
bronchospasm, thick secretions, and respiratory muscle fatigue are
some of the causes of an ineffective cough.

Normal secretion is clear or gray and minimal; abnormal sputum is

Assess the amount, color, odor and
green, yellow, or bloody; malodorous; often copious. Thick
viscosity of the secretions.
tenacious secretions increase airway resistance.

Monitor oxygen saturation using An oxygen saturation of less than 90% indicates problems with
pulse oximetry. oxygenation.

Chest x-ray provides information regarding the presence of

Monitor chest x-ray results.
infiltrates, lung inflation, or the presence of barotrauma.

Monitor laboratory results as indicated:

White blood cell count. Increased WBC count indicates an infection.

The use of beta-adrenergic agonists shift potassium into the cell

Potassium.
and cause hypokalemia.

Therapeutic range of theophylline is between 10 to 20 mcg/mL.

Theophylline level (if on
Signs of toxicity includes hypotension, tachycardia, GI symptoms,
theophylline therapy).
and restlessness.

Monitor arterial blood gasses Retention of carbon dioxide happens due to fatigue from labored
(ABGs). breathing caused by bronchospasm. Once the client is
mechanically ventilated, permissive hypercapnia may be utilized
 to prevent lung damage and maintain plateau pressure less than 30
to 35 cm H20.

Peak expiratory flow rate (PEFR) is the maximum flow rate

Obtain peak expiratory flow rate
generated during a forceful exhalation. It should be improved with
(PEFR) or forced expiratory volume
effective therapy. FEV1 is the volume exhaled during the first
in 1 second (FEV1) before and after
second of a forced expiratory maneuver started from the level of
respiratory treatment.
total lung capacity.

e.g., Break up activities into smaller parts and take rest breaks in
Pace client’s activities.
between to avoid fatigue. increased effort in breathing properly.

Keeping the client calm will prevent the occurrence of an asthma

Reduce client’s anxiety.
attack.

Encourage increased fluid intake of

Fluids help minimize mucosal drying and increases ciliary action
up to 3000 ml/day within cardiac or
to remove secretions.
renal reserve.

IV fluid therapy can be beneficial for clients with dehydration.

Administer IV fluids and
Medications such as bronchodilators and inhaled corticosteroids
medication as ordered.
may be prescribed.

Oxygen therapy corrects hypoxemia, which can be caused by

Administer oxygen as ordered.
retained respiratory secretions.

Anticipate the need for intubation Acute exacerbations of asthma can lead to respiratory failure
and mechanical ventilation. requiring mechanical ventilation.
Deficient Knowledge

Deficient Knowledge: Absence or deficiency of cognitive information related

to specific topic.

May be related to

 Chronicity of disease.
 Lack of information sources.
 Long-term medical management.

Possibly evidenced by

 Absence of questions.
 Ineffective self-care.
 Inability to answer properly.

Desired Outcomes

 Client and significant others will verbalize knowledge of the disease

and its management and community resource available to help the
client in coping with chronic disease.

Nursing Interventions Rationale

Assess the client’s knowledge of care for status

Knowledge on how to handle care can save time.
asthmaticus, as appropriate.

Assess past and present therapies, including Knowledge of what has been effective in the past
client’s response to them. determines the appropriate intervention needed.

Assess the client’s knowledge of asthma triggers Identifying the asthma triggers will make the client
and asthma medications: know how to control them; Correct use of spacers
by slow, deep inhalation and breath-holding after
 Treatment for status asthmaticus. inhalation will ensure the effectiveness of the
  Correct use of metered-dose inhaler
(MDI) and space.
 Use of spacers with an MDI.
 Ability to distinguish between rescue
medications and controllers.
Assess the client’s tobacco use.
Evaluate self-care activities: preventive care and
home management of an acute attack.
Explain the disease to the client and significant
others.
Instruct the client how to avoid asthma triggers:
 Smoke.
 Exercise
 Air pollution.
 Allergens.
Educate the client about the warning signs and
symptoms of an asthma attack and the importance
of early treatment of an impending attack. Provide
a written copy of daily exacerbation management.
Review all medications with the client including a
discussion of short versus long-acting
medications, a review of zones, and the dosage of
each medication in each zone.
medication. Improper use of an MDI will lead in the
medications not getting deep enough to affect the
airway.
Assessment of tobacco use is important for clients
suffering from lung disease. If the client is a tobacco
user, cessation of smoking should be stressed.
Since it is a chronic disease, the client must be able
to self-manage the disease.
A misconception regarding asthma attack is that it
can be managed without medication through self-
control and discipline. Knowledge on asthma self-
management reduces the need for frequent
hospitalizations.
Environmental trigger control can lessen the
frequency of asthma attacks and improve the
client’s quality of life.
Written treatment plan is needed by the client to
reinforce information that was already taught. Early
treatment within 6 hours of an attack may lessen the
chance of hospitalization.
Short-acting beta-agonist are the first line
medication of choice since they relieve acute
asthma attacks very quickly compared to the long-
acting. Beta-2-adrenergic agonist should be used
before inhaled steroids since they open the airways
and allow the anti-inflammatory medication to reach
deeper into the lung fields. Rinsing the mouth after
using an inhaled steroids prevents yeast infection.
Anti-inflammatory medications, such as inhaled
steroids, work by reducing swelling and mucus
production in the airways. As a result, the airways
are less sensitive and less likely to respond to
asthma triggers and cause asthma symptoms.

Reinforce the need for taking controller
medications as indicated.
Teach how to administer nebulizer treatments,
Diskus, MDIs spacers, or dry powder capsules
with the correct technique.
Instruct in the use of peak flow meters and
develop an individualized plan on how to adjust
medications and when to seek medical advice.
Establish the client’s personal best peak expiratory
flow rate (PEFR).
Discuss the importance of
pneumococcal pneumonia vaccine and influenza
vaccine yearly.
Reinforce what to do in an asthma attack (Home
management and prevention ,and when to seek
urgent hospitalization).
Address the long-term management issues.
Asthma is a chronic condition that is present even
when attacks are not occurring. Medications such as
bronchodilators and anti-inflammatory agents
reduce the incidence of attacks.
Providing return demonstrations on techniques are
needed to ensure appropriate delivery of the
medication.
Use the zone system individualized to the client.
Personal best is established by having the client take
and document peak flow each morning before
medication use and in the late afternoon for 2
weeks. Personal best is the highest peak flow
reading regularly blown, which is then used to
calculate the client’s zone.
 Green Zone: 80 to 100% of the usual or
“normal” peak flow rate signals all clear.
 Yellow Zone: 50 to 80% of the usual or
“normal” peak flow rate signals caution. A
temporary increase in medication may be
needed.
 Red Zone: Less than 50% of the usual or
“normal” peak flow rate signals a Medical
Alert. A beta-adrenergic agonist is usually
taken, and if there is no improvement in
PEFR to yellow or green zones, the
physician is notified.
Regular immunizations reduce the chance of
acquiring these diseases.
Information enables the client to take control and
reduce life-threatening complications.
Hospitalization is required for severe exacerbations,
severity of the condition and poor response to
treatment.
Control of allergens, avoidance of precipitators,
environmental control, avoidance of air pollutants
such as perfumes, aerosol sprays, powder, and

Discuss the use of a medical alert bracelet or other
identification.
Instruct the client to keep emergency phone
numbers readily available.
Refer to support groups, as appropriate.
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health habits prevents the occurrence of asthma
attacks.
These identification alert others to an asthma history
to facilitate the delivery of safe, effective medical
care.
These will help in seeking immediate medical
attention.
Asthma support groups offer an environment in
which client can learn new ways of dealing with the
illness and appropriate health behavior changes such
as smoking cessation.
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