Running head: CONCEPT MAP DRAFT PART B

Concept Map Draft Part B: Ineffective Airway Clearance

Sadiq Adisa Bello
Humber College
Complex Issues and Patient Safety (NURS 252)
Submitted to: Vasanthy Harnanan
14th March, 2016

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CONCEPT MAP DRAFT PART B
Respiration forms a vital source of our life. Maintaining a clear airway
to promote breathing ensures life continuity. Airway maintenance forms part
of the assessment for nursing priority intervention because maintaining a
pathway for breathing without blockage ensures better chances of
resuscitating a person from further complication. Blockage of the airways
decreases oxygen supplies to extremities to the body leading to cell death or
organ malfunction and in the worst cases brain damage as in case of
syncope Obstructions not only reduce the intake of air into the respiratory
system, but also create a more turbulent flow of air in the trachea and upper
airway. This turbulence disturbs the laminar airflow required in the lower
respiratory tract to facilitate efficient exchange of gases (Scott, 2012).
Assessment for patient with ineffective airway clearance reveals low oxygen
saturation on pulse oximeter reading, shortness of breath, fatigue, use of
accessory muscle, cyanosis on lips and other extremities. All these signs and
symptoms signify clues for nurses to know the impending or upcoming
interventions that need to be utilized to prevent further complications.
Assessment revealing an oxygen saturation level of 92% on R.A
experienced by the client shows impaired gaseous exchange level due to
ineffective airway clearance which needs immediate attention as maintaining
an active airway increases chances of survival of patient. Due to the
impaired gaseous exchange, fatigue sets in making it more difficult to keep

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up with oxygen demands leading to weakness and muscle pain as
experienced by the client Fatigue is associated with the increased work of
breathing and the struggle to maintain adequate oxygenation when these
responses occur (Carlson et al.,1998). Interventions to deal with ineffective
airway clearance related to fatigue include position client in semi fowler
position and change position every 2-3 hr, encourage and teach purse lip
breathing to client every two hour intervals, administer 2 litres of oxygen by
nasal prongs as ordered by physician, provide humidifier to loosen mucus to
ease breathing and administration of corticosteroids or MDI as ordered by
physician. All these interventions if taken into consideration will greatly
improve the airway maintenance of client having ineffective airway
clearance resulting in low oxygen saturation level and impaired gaseous
exchange in extremities.
Positioning the client in semi fowler position helps to open up the
airway and allows the client to breath efficiently. It allows the use diaphragm
muscle effectively and also prolongs expiratory phrase of breathing (Lewis,
2012 p.748). This position allows convenience for nurses to administer
medication ordered by the doctor such as MDIs and corticosteroids.
Maintaining the client in semi-fowlers position ensures constant aeration of
the airway and provides comfort for the client.
Teaching the client breathing techniques such as pursed-lip breathing
increases amount of oxygen being carried into lung and effective expiration

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of carbon dioxide out of lungs. Performing this intervention every two hours
will help the client to achieve a stable oxygen saturation level. This
technique of breathing also aid in relaxation of client and prevent the use of
accessory muscle during breathing Patients with airways obstruction
sometimes purse their lips during expiration, called pursed lips breathing,
and claim an immediate subjective benefit. This type of breathing results in a
positive expiratory pressure (PEP) and it is thought to have similarities with
continuous positive airway pressure and positive end-expiratory pressure
(Schan et al., 1994 para. 2)
Administering 2 litres of oxygen by nasal prongs as ordered by
physician is also an important intervention for client as decreasing oxygen
level pose life threatening situation. This intervention augmented with the
former two addressed in paragraphs will help to provide oxygen supply to the
lung effectively without the patient having to compete for air oxygen. The
percentage of oxygen in air is about 21% therefore, having a straight supply
of oxygen attached to nares provide a direct flow of this natural gas into the
lungs because the larger percentage of air being breathed is nitrogen An
increased level of inspired oxygen increases alveolar oxygen partial pressure
and decrease nitrogen partial pressure (Zeirold, Lee, Subramanian &
Dubois, 2000, Para.2)
Also, provision of humidifier helps loosen mucus which aids breathing.
This intervention for the client is equally important as the overall goal is to

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allow patient have a good airway clearance. Mucus accumulation in the lungs
provides a good environment for viruses, bacteria and fungi to multiply The
secretions that accumulate behind the obstruction provide a rich medium for
growth of bacteria, viruses, and fungi, all of which may cause infection
(Lewis, 2012 p.640). Use of humidifier helps to moisten secretion and
prevents dryness around nasal cannula thereby reducing nasal bleed Lack
of humidification leads to drying of secretions and nasal bleeding with
resultant increased airway resistance and/or obstruction (Bassham et al.,
2012).
Administration of corticosteroids and metered dose inhaler as ordered
by physician is a pharmacological intervention adopted for the client to
improve airway clearance. Combination of both drugs prevents client from
having an obstructive airway In chronic obstructive pulmonary disease,
inhaled corticosteroids improve symptoms, reduce frequency of
exacerbations and hospitalizations, and should be considered in patients with
moderate-to-severe airflow limitation who have persistent symptoms despite
optimal bronchodilator therapy (Phua & Maclntyre, 2007)
In conclusion, interventions adopted for client experiencing ineffective
airway clearance related to fatigue was positioning of client in semi fowler
position which gives comfort and ensures unobstructed airway for breathing.
Purse lip breathing and administration of oxygen by nasal prongs as ordered
by physician will increase oxygen supplies to extremities thereby increasing

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oxygen saturation levels. Adoption of the above mentioned interventions will
greatly impact the airway clearance of client as breathing is one of the basic
needs on the Maslow hierarchy of needs and a priority intervention that
needs to be addressed quickly.

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