Ineffective Airway Clearance Definition: The inability to clear secretions or obstacle of the respiratory tract to keep airway hygiene.
Limitation of Characteristics:
Related factors:
NOC - Ineffective Airway Clearance of COPD:
Expected outcomes are:
NIC - Ineffective Airway Clearance of COPD :
(1) Airway Suction
(2) Airway Management
Limitation of Characteristics:
- Dyspnoea, decrease inwards breath sounds
- Orthopneu
- Cyanosis
- Abnormalities of breath sounds (rales, wheezing)
- Difficulty speaking
- Cough, ineffective or no
- Eyes widened
- Production of sputum
- Fidget
- Changes inwards frequency as well as beat of the breath
Related factors:
- Environment: smoking, tobacco smoke, passive smoking, infection
- Physiological: neuromuscular dysfunction, hyperplasia of the bronchial wall, airway allergy, asthma.
- Obstruction of the airway: airway spasm, secretion retention, the sum of mucus, the artificial airway, bronchial secretions, presence of exudate inwards the alveoli, the presence of unusual bodies inwards the airway.
NOC - Ineffective Airway Clearance of COPD:
- Respiratory status: Ventilation
- Respiratory status: Airway patency
- Aspiration control
Expected outcomes are:
- Demonstrate effective coughing as well as breath sounds are clean, no cyanosis as well as dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
- Showed a patent airway (the customer does non experience suffocated, breath rhythm, respiratory frequency inwards the normal range, at that topographic point is no abnormal breath sounds)
- Able to position as well as forestall factors that tin inhibit airway.
NIC - Ineffective Airway Clearance of COPD :
(1) Airway Suction
- Make certain the needs of oral / tracheal suctioning
- Auscultation of breath sounds earlier as well as later suctioning.
- Inform the customer as well as position unit of measurement nearly suctioning
- Ask the customer to produce a deep breath earlier suction.
- Give oxygen using nasal to facilitate suksion nasotrakeal
- Use sterile tools that every action
- Instruct the patient to relaxation as well as breathe inwards later the catheter removed from nasotrakeal
- Monitor patient's oxygen status
- Teach the position unit of measurement how to perform suction
- Stop suksion as well as give oxygen if the patient showed bradycardia, increased oxygen saturation, etc..
(2) Airway Management
- Open the airway, mentum elevator technique guanakan or jaw thrust if necessary
- Position the patient to maximize ventilation
- Identify the patient's require for the installation of an artificial airway device
- Replace the mayo if needed
- Perform breast physiotherapy if necessary
- Remove secretions past times coughing or suctioning
- Auscultation of breath sounds, banker's complaint the presence of additional noise
- Apply suction to the mayo
- Give bronchodilators if necessary
- Provide NaCl humidifiers Damp moisture gauze
- Adjust intake to optimize fluid balance.
- Monitor respiration as well as oxygen status