What is the rationale for this nursing diagnosis

brandi110 · Feb 6, 2008

Hello everyone.. i'm here again asking for your help..
What is the rationale of his nursing diagnosis: Ineffective airway clearance related to thick mucus production secondary to pulmonary tuberculosis?
im not sure if this prioritized nursing diagnosis for our NCP is correct. please correct me if im wrong & help me rationalize this & relate this to our PTB patient..
Please.. i really need this as soon as possible.. our case presentation is coming this saturday & it is our first time to have this case presentation.. our group is not yet ready & we havent finish everything.. Aside from our exam is on Friday.. huh...
Thanks in advance...

Ineffective airway clearance adresses the inability to cough effectively. The is evidenced by the thick mucus production (which shows an inability to remove airway secretions, a major defining characteristic for the nursing diagnosis Ineffective Airway Clearance). Secondary just gives the medical diagnosis for the problem which is pulmonary tuberculosis. The care plan interventions for this diagnosis could be teaching client sitting positions, coughing and deep breathing exercises, maintaining hydration and humidity of inspired airway, ambulation. Im a new student as well so check with other resources to ensure accuracy and good luck.

Daytonite, BSN, RN · Feb 6, 2008

The rationale (reason) you are using this diagnosis has to do with what is going on in the patient's lungs. The NANDA taxonomy actually gives you many of the rationales for the nursing diagnoses. In the case of Ineffective Airway Clearance, they give a whole bunch:

Environmental
- secondhand smoke
- smoke inhalation
- smoking
[*]Obstructed airway
- airway spasm
- excessive mucus
- exudate in the alveoli
- foreign body in airway
- presence of artificial airway
- retained secretions
- secretions in the bronchi
[*]Physiological
- allergic airways
- asthma
- chronic obstructive pulmonary disease
- hyperplasia of the bronchial walls
- infection
- neuromuscular dysfunction
- (page 5, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008)

In the case of PTB, the rationale is infection. Inflammation accompanies infection. The tuberculin infection evokes the inflammation response (redness, heat, swelling, and pain), but there are other events going on as well, such as the production of pus which is a by-product of the body attempting to fight off the infection. The buildup of these products as well as the tissue being irritated by histamine results in over production of mucus, and thus, excess mucus production. Also, with the TB disease itself, cells are dying and necrotic. There is also bleeding. These are some of the factors (rationales) for what is obstructing the airway as well.

Rationales have to do with asking "why am I using/doing. . .". In this case you must ask "why am I using this diagnosis?" The reason (rationale) is because of what the infection and inflammation are causing to occur in the lung tissue that results in the overproduction of mucus.

If you read the actual definition of this diagnosis it says: inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. That is the true nursing problem here.