Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

May be related to:

• Increased amount/viscosity of secretions
• Restricted chest movement/pain
• Fatigue/weakness

Possibly evidenced by:

• Changes in rate/depth of respiration
• Abnormal breath sounds
• Ineffective cough
• Dyspnea

Desired Outcomes:
Show a patent airway by exhaling easily with clear breath sounds and breathing without making any noise.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Impaired gas After 8 hours of Assess respirations: 1. Respiratory After 8 hours of
The client reports he exchange RT nurse-patient • Note quality distress nurse-patient
“finds it is difficult to collection of mucus interventions the • Rate symptoms interventions the
breathe” in airways. patient will be able • Rhythm depend on patient was able to:
to: • Depth and are a
OBJECTIVE: demonstrates • Use of good • Maintain
+ Abnormal breath methods for accessory indicator of optimal gas
sounds enhancing gas muscles the extent of exchange as
+ Dyspnea exchange • The position lung evidenced by
HR- bpm assumed for involvement. usual mental
Restlessness Maintain appropriate easy status.
mental status and breathing 2. As patients • Normal
oximetry readings will modify oximetry
while maintaining Elevate the head and their results.
adequate gas encourage frequent breathing
exchange. patterns to
position changes, facilitate • Demonstrate
deep breathing, and efficient gas techniques to
effective coughing. exchange, improve gas
the exchange.
underlying
general
health status
is important.
3. These actions
encourage
the largest
possible
expansion of
the chest,
mobilize
secretions,
and enhance
ventilation.