Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Ineffective Airway Clearance related to Sinusitis - Nursing Diagnosis and Interventions

Ineffective Airway Clearance
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
Sinusitis is often mistaken as a common cold; whereas, a common cold is a problem of the whole upper respiratory system whilst sinusitis only refers to the inflammation of just the sinuses.
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

Acute Pain Nursing Diagnosis for BPH

Acute Pain related to the irritation of bladder mucosa, bladder distension, renal colic, urinary infection.

Goal :
Pain is reduced / lost

Criteria for outcome :

Clients reported no pain, showed the skills of relaxation and therapeutic activity according to indications for individual situations. Seemed relaxed, sleep / rest appropriately.

Plan of action and rational :
  • Review the pain, note the location, intensity (scale 0 - 10).
    R / Pain sharp, intermittent with the urge to urinate / massage urine around the catheter showed bladder spasm, which tends to be more heavily on the approach of TURP (usually decreased within 48 hours).
  • Keep the catheter and drainage system. Keep the hose free of grooves and clot.
    R / Maintaining the function of the catheter and drainage system, reducing distension risk.
  • Maintain bed rest if indicated
    R / required during the early phase during the acute phase.
  • Provide comfort measures (therapeutic touch, changing positions, massage your back) and therapeutic activity.
    R / Reduces muscle tension, back memfokusksn attention and can enhance coping ability.
  • Collaboration in the provision antispasmodik
    R / Eliminates spasm


Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is the medical term, but we all know it more commonly as an enlarged prostate. Increasingly common in men as they age, it is believed that potentially all men will suffer from BPH at some point in their lives if they live long enough.

The prostate gland is present only in males and is located around the urethra between the bladder and penis. According to The National Institutes of Health, it is estimated that as high as ninety percent of men over the age of 70 have some symptoms related to BPH. Basically, BPH is caused by a growth of the cells of the prostate gland, which causes the gland to enlarge and puts excess pressure on the urethra.

The exact cause of prostate enlargement isn't clearly understood. It is related to the functioning of the testicles and the hormones they produce, and also correlates with age. No risk factors for developing BPH are known, however men who have had their testicles removed - say, due to testicular cancer - will not develop enlargement of the prostate gland.
Nursing DIagnosis Risk for Infection related to Scabies

Nursing DIagnosis Risk for Infection related to Scabies

Scabies is an infectious skin condition which is caused by the parasitic mites beneath the surface of the skin. They could be spread from one human host to another, while coming into contact with the infested human being. These mites are microscopic in nature and hence the symptoms appear about one or two weeks after the infestation.

Scabies can cause a lot of discomfort during pregnancy. Studies have shown that insecticides used to cure scabies can adversely affect the embryo and hence can have a negative impact on the infant. Usually 6-8% of the scabies repellent is absorbed at the time when it is externally applied to the skin.

Permethrin is another effective medicine used for the treatment of scabies. It is also an insecticide and is sold as a 5% lotion. It does not pose any side effects and therefore is safe to use during pregnancy. In most cases, the first trimester of pregnancy is crucial and therefore care must be taken. Lactating women must not apply the scabicides on the breasts and must keep the child away, so that the condition is not infested in the child.

Nursing Diagnosis for Risk for Infection related to damaged skin tissue and invasive procedures

Goal :
Avoid the risk of infection

Criteria for outcome :
  • Clients are free from signs and symptoms of infection
  • Showing the ability to prevent infection
  • Demonstrate healthy behavior
  • Describe the process of transmission of disease, factors that affect transmission.

Plan of action :
  • Monitor signs and symptoms of infection
  • Monitor susceptibility to infection
  • Limit visitors when necessary
  • Instruct the guests to wash their hands during a visit and after leaving the patient
  • Maintain aseptic environment during installation tool
  • Give skin care in the area epidema
  • Inspection of skin and mucous membranes of the redness, hot
  • Inspection of the wound
  • Provide antibiotic therapy if necessary
  • Teach how to avoid infection.
Nursing DIagnosis Risk for Infection related to Scabies
Powered by Blogger.