Ineffective Airway Clearance of COPD

Ineffective Airway Clearance Definition: The inability to clear secretions or obstruction of the respiratory tract to maintain airway hygiene.

Limitation of Characteristics:

• Dyspnoea, decrease in breath sounds
• Orthopneu
• Cyanosis
• Abnormalities of breath sounds (rales, wheezing)
• Difficulty speaking
• Cough, ineffective or no
• Eyes widened
• Production of sputum
• Fidget
• Changes in frequency and rhythm 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 amount of mucus, the artificial airway, bronchial secretions, presence of exudate in the alveoli, the presence of foreign bodies in the airway.

NOC - Ineffective Airway Clearance of COPD:

• Respiratory status: Ventilation
• Respiratory status: Airway patency
• Aspiration control

Expected outcomes are:

• Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
• Showed a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
• Able to identify and prevent factors that can inhibit airway.

NIC - Ineffective Airway Clearance of COPD :

(1) Airway Suction

• Make sure the needs of oral / tracheal suctioning
• Auscultation of breath sounds before and after suctioning.
• Inform the client and family about suctioning
• Ask the client to do a deep breath before suction.
• Give oxygen using nasal to facilitate suksion nasotrakeal
• Use sterile tools that every action
• Instruct the patient to rest and breathe in after the catheter removed from nasotrakeal
• Monitor patient's oxygen status
• Teach the family how to perform suction
• Stop suksion and give oxygen if the patient showed bradycardia, increased oxygen saturation, etc..

(2) Airway Management

• Open the airway, chin lift technique guanakan or jaw thrust if necessary
• Position the patient to maximize ventilation
• Identify the patient's need for the installation of an artificial airway device
• Replace the mayo if needed
• Perform chest physiotherapy if necessary
• Remove secretions by coughing or suctioning
• Auscultation of breath sounds, note the presence of additional noise
• Apply suction to the mayo
• Give bronchodilators if necessary
• Provide NaCl humidifiers Damp wet gauze
• Adjust intake to optimize fluid balance.
• Monitor respiration and oxygen status

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