Nanda, Nursing Care Plan, Nursing Assessment, Nursing Diagnosis, Nursing Interventions

Nursing Actions for Ineffective Airway Clearance related to COPD


Chronic Obstructive Pulmonary Disease (COPD) is a disease characterized by the air flow resistance in the airway that is not fully reversible. This air flow resistance is progressive and associated with an inflammatory response of the lungs to particles or gases which are toxic or dangerous.

In assessing the clinical manifestations of COPD should consider the following matters:
  • Onset (onset of disease) is usually in middle age.
  • The development of symptoms, is slowly progressive.
  • A history of exposure, such as smoking, air pollution (indoor, outdoor and workplace).
  • Shortness of breath during activity.
  • Air flow resistance is generally irreversible (can not be back to normal).
COPD symptoms mainly related to respiration. This respiratory complaints must be examined carefully because it is often regarded as a symptom which is common in the aging process.
  • Chronic cough. : Chronic cough is a cough that intermittent during the three months that did not disappear with treatment.
  • Chronic phlegm. Sometimes patients stated that only phlegm continuously without coughing.
  • Shortness of breath. Especially when doing the activity. Often patients are already experiencing adaptation by shortness of breath, which is a slow progressive so do not complain of shortness of breath.

Care Plan


Ineffective Airway Clearance related to inadequate cough, increased mucus production

Objective: The client can increase airway clearance.

Expected results: the patient will :
Able to demonstrate controlled cough.
Adequate fluid intake.

Nursing Actions :

1. Assess client's ability to mobilize secretions, if it is not able to:
  • Teach method controlled cough.
  • Use suction (if necessary to remove secretions).
  • Perform chest physiotherapy.
2. Regularly every 8 hours, do chest auscultation breath sounds to determine the quality and progress.

3. Give the medications as prescribed; mucolytics, expectorant.

4. Encourage drink approximately two liters per day if there are no contraindications.

5. Encourage the client to prevent infection / stressor
  • Prevent a crowded room visitors or contact with individuals suffering from influenza.
  • Prevent irritation of cigarette smoke.
  • Immunizations: Influenza vaccination.
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