Ineffective Airway Clearance NANDA Definition : : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Pneumonia is a lung infection that can be caused by different types of microorganisms, including bacteria, viruses, and fungi.
Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung.
Symptoms of pneumonia caused by bacteria usually come on quickly. They may include:
- Cough. You will likely cough up mucus (sputum) from your lungs. Mucus may be rusty or green or tinged with blood.
- Fever.
- Fast breathing and feeling short of breath.
- Shaking and "teeth-chattering" chills. You may have this only one time or many times.
- Chest pain that often feels worse when you cough or breathe in.
- Fast heartbeat.
- Feeling very tired or feeling very weak.
- Nausea and vomiting.
- Diarrhea.
When you have mild symptoms, your doctor may call this "walking pneumonia."
Nursing Diagnosis for Pneumonia : Ineffective Airway Clearance
related to
- Pleuritic pain
- Decreased energy, fatigue
- Tracheal bronchial inflammation, edema formation, increased sputum production
Possibly evidenced by
- Abnormal breath sounds, use of accessory muscles
- Cough, effective or ineffective; with/without sputum production
- Dyspnea, cyanosis
- Changes in rate, depth of respirations
Outcomes
- Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
- Identify/demonstrate behaviors to achieve airway clearance.
Interventions and Rationale :
1. Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.
R : Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.
2. Assess rate/depth of respirations and chest movement.
R : Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
3. Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position.
R : Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.
4. Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.
R : Fluids (especially warm liquids) aid in mobilization and expectoration of secretions.
5. Monitor serial chest x-rays, ABGs, pulse oximetry readings.
R : Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.