Ineffective Airway Clearance | allnurses

Ineffective Airway Clearance

  1. 0 Hi, I'm a nursing student here in Ga. We have to complete a concept map on a patient.
    My patient is a 48 yr old male who was in a vehicle accident who suffered head trauma. My number one diagnosis is ineffective airway clearance rt to ineffective coughing. I need some help on coming up with some measurable goals for him. I dont know if i would set a goal to get him to cough because the doctor couldnt get him to cough due to his paralysis. I'd really appreciate the help.Thanks.
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  2. 13 Comments

  3. Visit  Daytonite profile page
    #1 1
    see http://allnurses.com/nursing-student...cp-372845.html - need help for ncp

    i worked with respiratory patients for many years. know what i used to do to get them to cough? tell them jokes to get them to laugh. they can't laugh without coughing. i had a whole repertoire of simple little one liners. you can find all kinds on these on the internet. also, take a sheet off the linen cart and leaving it folded lengthwise wrap it tightly around his waist like you are going to strangle him (this is splinting) and have him cough. there are ways to physically stimulate the cough reflex as well, but i would not attempt them without physician approval.

    another way to think of goals is that they are what you expect to happen as a result of your nursing interventions being performed. so, whatever you decide to use as your interventions. . .your goals should be a reflection of those interventions.
  4. Visit  arenars profile page
    #2 0
    So would if my interventions included : raising head of bed so as not to aspirate with foods and liquids, chewing food completely, and getting him to cough, what could i put for a measurable goal? Could it be Patient will Prevent aspiration by completely chewing 100% of food?
  5. Visit  kids profile page
    #3 1
    People prone to aspiration will do it no matter how well chewed their food is

    I think you're headed off in the wrong direction by focusing on aspiration in this problem. Aspiration is usually it's own nursing diagnosis with it's own set of interventions and goals.

    Daytonite mentioned splinting, other interventions include postural drainage and chest percussion or the use of something like this http://www.thevest.com/. There is also this http://www.coughassist.com/
    which I've seen more and more patients getting lately.

    Your goals would focus around the ABCs and be able to be assessed consistently by different care givers (lung sounds, O2 sats, color, temp).
  6. Visit  Daytonite profile page
    #4 0
    Assisting with not aspirating food and fluids belongs with Risk for Aspiration. When patients cannot initiate cough on their own secretions build up and eventually the patient will cough when moved and repositioned and with P&PD. They may also need to be suctioned.
  7. Visit  arenars profile page
    #5 0
    Ok I think i know what you're getting at. I should focus on the actually keeping a patent airway, so my goal could be, "Patient will maintain normal respirations of 16-20 maintaining a patent airway", or focus on getting him to cough "patient will cough 2 times in 1 day"
  8. Visit  Daytonite profile page
    #6 0
    Quote from arenars
    Ok I think i know what you're getting at. I should focus on the actually keeping a patent airway, so my goal could be, "Patient will maintain normal respirations of 16-20 maintaining a patent airway", or focus on getting him to cough "patient will cough 2 times in 1 day"
    Will your nursing interventions accomplish these?
  9. Visit  arenars profile page
    #7 0
    Well, I could add postioning him in high fowler's, auscultating him, encouraging activty and ambulation. with these interventions, i think it would help him maintain a patent airway. i would add deep breathing and forceful cough but he has cognitive impairement.Also my patient has paralysis on one side of his body. so there is always a constant risk for not mantaining a patent airway .I dont know if he would be able cough if he was to ever choke.
  10. Visit  Daytonite profile page
    #8 0
    You keep bringing up choking and that is not what Ineffective Airway Clearance is about. Maybe you have misdiagnosed this patient.
  11. Visit  arenars profile page
    #9 0
    But wouldnt a risk for aspirating be higher than my other top two diagnosis which are excess fluid volume rt head injury, and caridac output decreased rt high blood pressure? Its not that he has pnemonia or cystic fibrosis in which he has trouble removing mucous, but again (im sorry to bring the choking up again) he's just at high risk of not being able to remove the fluids he chokes on.Maybe I could change it to ineffective airway clearance rt inability to remove secretions as manifested by inefective cough.
  12. Visit  Daytonite profile page
    #10 0
    a potential problem, which is what a risk for aspiration is, never a priority over actual problems which is what your ineffective airway clearance is.
  13. Visit  arenars profile page
    #11 0
    Ok. Well I really appreciate the help daytonite. Sorry it took so long to finally get it. This is my first concept map so i'm having a little trouble coming up with the goal. But i'll get better.
  14. Visit  Daytonite profile page
    #12 0
    ineffective airway clearance rt inability to remove secretions as manifested by inefective cough
    yes, with time and experience you will get better at this. looking again at the diagnosis you proposed i missed pointing out something to you last evening. the inability to remove secretions is merely a restatement of the definition of this nursing problem and, therefore, cannot be a related factor, or etiology, of it.
    i understand that as a beginner at this it can be frustrating. this is nursing language combined with the nursing process and how you are being trained to think to do the job. trust me and other veterans of the profession that this is the way we want you to rationalize out these problems. when we get this person's secretions cleared, choking is off the table. this is only one nursing problem. there are 206 other ones.

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