Airway Clearance
Airway
Under the larynx, the airway can be divided into three components, namely :
Understanding uncleanness airway
A situation in which individuals experience a real threat or risk to the respiratory status with respect to the inability to effectively cough.
Ineffective airway clearance is the inability to clear the secretions or obstruction of the respiratory tract to maintain airway clearance (Nanda, 2005).
Intermittent obstructive airway disease, reversible where tracheo bronchial hyperactivity response to certain stimuli.
Uncleanness of the airway is the inability to clear secretions or obstruction of the respiratory tract to maintain the cleanliness of the airway.
Clinical Manifestations
Related Factors
a. Environment.
Smoke , inhale cigarette smoke.
b. Airway obstruction.
Airway spasm, excess mucus, exudate in the alveoli, foreign material in the airway, the presence of airway assistance.
c. Physiological.
Airway allergic, asthma, obstructive pulmonary disease, bronchial wall hyperplasia.
Examples of Disease
Some examples of diseases and many others related to airway clearance :
1. Bronchiecthasis
2. Pneumonia
Is an infectious disease that can be caused by :
3. Pulmonary Tuberculosis
4. Asthma
5. Bronchitis
6. Pleural effusion
7. And others.
Nursing diagnoses that may arise :
1. Ineffective airway clearance related to increased secretions.
2. Ineffective breathing pattern related to the narrowing of the bronchial airways.
Nursing Interventions :
1. Ineffective airway clearance related to increased secretions.
Purpose :
The effectiveness of the airway and are able to maintain the patent.
Expected outcomes :
Interventions :
Rationale :
2. Ineffective breathing pattern related to the narrowing of the bronchial airways.
Purpose :
Effective breathing pattern.
Expected outcomes :
Interventions :
Airway
Under the larynx, the airway can be divided into three components, namely :
- Conducting airways ; consists of the trachea, bronchi and bronchioles ending with the terminal.
- Transitional airways ; consists of respiratory bronchioles where gas flowed and there were a number of gas exchange.
- alveolar duct, and alveolar sacs, where gas exchange takes place with pulmonary capillary blood.
Understanding uncleanness airway
A situation in which individuals experience a real threat or risk to the respiratory status with respect to the inability to effectively cough.
Ineffective airway clearance is the inability to clear the secretions or obstruction of the respiratory tract to maintain airway clearance (Nanda, 2005).
Intermittent obstructive airway disease, reversible where tracheo bronchial hyperactivity response to certain stimuli.
Uncleanness of the airway is the inability to clear secretions or obstruction of the respiratory tract to maintain the cleanliness of the airway.
Clinical Manifestations
- Defining characteristics of ineffective airway clearance :
- Dyspnea.
- Decreased breath sounds.
- Orthopnea.
- Additional breath sounds : rales, crackles, rhonchi, whezing.
- There is no cough
- Excessive sputum production.
- Cyanosis.
- Difficulty speaking.
- Eyes widened.
- Changes in the frequency of respiratory rhythm and
- Restless.
Related Factors
a. Environment.
Smoke , inhale cigarette smoke.
b. Airway obstruction.
Airway spasm, excess mucus, exudate in the alveoli, foreign material in the airway, the presence of airway assistance.
c. Physiological.
Airway allergic, asthma, obstructive pulmonary disease, bronchial wall hyperplasia.
Examples of Disease
Some examples of diseases and many others related to airway clearance :
1. Bronchiecthasis
- This disease occurs in an abnormal widening of the bronchi and bronchial wall damage.
- Airway obstruction.
- Less immune response against the body.
2. Pneumonia
Is an infectious disease that can be caused by :
- Influenza Virus.
- Streptococcus aureus.
- Streptococcus pneumoniae.
- Shortness of breath, cough, fever, sweating.
3. Pulmonary Tuberculosis
- Pulmonary disease caused by microbacterium Tuberculosa and is highly contagious through sputum issued sufferers.
- Weight loss, excessive fatigue, fever, night sweats, and cough.
4. Asthma
- Obstructive airway disease is intermittent, reversible hyperactivity where tracheobronchial responds to certain stimuli.
5. Bronchitis
- Bronchitis is an inflammation of the bronchial tubes, or bronchi. Inflammation is caused by viruses, bacteria, smoke, or air pollution.
6. Pleural effusion
- Pleural effusion is the term used for the accumulation of fluid in the pleural cavity .
7. And others.
Nursing diagnoses that may arise :
1. Ineffective airway clearance related to increased secretions.
2. Ineffective breathing pattern related to the narrowing of the bronchial airways.
Nursing Interventions :
1. Ineffective airway clearance related to increased secretions.
Purpose :
The effectiveness of the airway and are able to maintain the patent.
Expected outcomes :
- There is no noise added.
- RR 16-24 per minute.
- The speed and depth of breathing normally.
- Not occur sionasis dyspnea.
- Decreased cough, and nonproductive.
Interventions :
- Auscultation of the airway, note the presence of wheezing, crackles, rales.
- Maintain a minimal environmental pollution such as : dust, feather pillows.
- Give a comfortable position with head of bed elevation, or semi-Fowler's position.
- Assess the effectiveness of cough and cough teach effectively.
- Give action nebulizer, inhalation.
- Collaborate with physicians in the delivery of bronchodilator treatment.
Rationale :
- To find signs of airway disorders.
- Reduce the risk of allergen hypersensitivity effects.
- To maximize lung expansion.
- To issue secret with coughed.
- To loosen airway.
- To relieve airway.
2. Ineffective breathing pattern related to the narrowing of the bronchial airways.
Purpose :
Effective breathing pattern.
Expected outcomes :
- RR : 16-24 times per minute.
Interventions :
- Vital signs on a regular basis.
- Assess skin color of the mucous membranes.
- Collaborate with physicians to oxygen therapy.
- Semi-Fowler position.
- Provide appropriate blood transfusion if necessary calculations.
- To determine the current state of the client.
- Knowing the existence and degree of disturbance.
- Oxygen administration reduce the workload of the respiratory muscles.
- Make maximum lung expansion and facilitate oxygen uptake.
- To create an adequate supply of oxygen throughout the body.
