Primary Nursing Diagnosis

Ineffective airway clearance related to obstruction from narrowed lumen and thick mucus

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suc-tioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring


Patients often require intravenous fluid replacement. Unless contraindicated by a cardiac problem, 3000 to 4000 mL/day of fluid is usually administered intravenously, which helps loosen secretions and facilitates expectoration of the secretions. Low-flow oxygen therapy based on arterial blood gas results is often administered to treat hypoxemia. For the patient with increasing airway obstruction, endotracheal intubation and perhaps mechanical ventilation may be needed to maintain adequate airway and breathing. Close follow-up is needed when patients are discharged from the hospital because airway hyperactivity usually persists for 4 to 6 weeks after the event.

Pharmacologic Highlights

Medication or Drug Class





Varies by drug

Inhaled beta2-adrenergic

Reversal of airflow obstruction

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