NANDA Definition:
Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.
Sinusitis
The sinuses are cavities filled with air that are located in the nasal area. These can be inflamed when irritated.
Sinus infection can be caused by inhalation or exposure to viruses, bacteria or fungi.
There are about 3 popular forms of sinusitis characterized by the frequency they occur. The first would be acute sinusitis. A person has acute sinusitis if her sinuses are inflamed for about 3 weeks. If a person shows symptoms of sinusitis for about 3 months, then that person has acute sinusitis. But if a person experiences acute sinusitis non consequently then that person is considered to have recurrent sinusitis.
Sinusitis can also be classified by the part of the sinus it affects. Maxillary sinusitis affects the cheek area and causes headaches and toothaches.
Frontal sinusitis and ethmoid cause headaches in the frontal cavities which are located near the eyes.
Sinusitis can be caused by many things. Viral infections, air pollution, like smoking and exposure to second-hand smoke, and allergies are just some of the elements that increase your chance of having sinusitis.
Nursing Diagnosis Ineffective airway clearance related to obstruction (the accumulation of nasal secretions) secondary to inflammation of the sinuses
Goal :
Effective airway after secret (seous, purulent) issued
Criteria for outcome :
- The client no longer breathe through the mouth
- Street breathing returned to normal, especially the nose
Nursing Interventions Ineffective Airway Clearance for Sinusitis:
- Review the existing buildup of secretions
R /: Determine the level of severity and subsequent action - Observation of vital signs
R /: Knowing the client's progress prior to surgery - Collaboration with the medical team for cleaning discharge
R /: Co-operation to eliminate the buildup of secretions.
Ineffective Airway Clearance related to Bronchiectasis
Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions
Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange