Nursing Diagnosis for Bronchiectasis : Ineffective Airway Clearance related to increased mucus production and decreased ability to cough effectively.
Goal: Effective airway, eliminating the quantity of sputum viscosity to improve pulmonary ventilation and gas exchange.
Outcomes:
- can demonstrate effective coughing,
- can mention the ways to lower the viscosity of secretions,
- no additional breath sounds,
- normal breathing (16-20 x / min) without the use of auxiliary breathing muscles.
1. Assess color, consistency, and amount of sputum.
R /: Characteristics of sputum may indicate the severity of the obstruction.
2. Adjust the position semifowler.
R /: Enhance chest expansion.
3. Teach cough effectively.
R /: Cough is controlled and can effectively facilitate the embedding secret spending airway.
4. Help clients practice a deep breath.
R /: maximum ventilation opening the airway lumen and increase the secret movement into the large airway to be issued.
5. Maintain fluid intake at least 2500 ml / day unless indicated.
R /: Adequate hydration helps thin the secret and effective airway clearance.
In addition, to increase the client's fluid intake is a tendency to breathe through the mouth which increases water loss. Inhalation of evaporated water vapor is also helpful because it can moisturize the bronchial branching.
6. Perform chest physiotherapy with postural drainage techniques, percussion, and vibration chest.
R /: Postural drainage with percussion and vibration using the help of gravity to help increase the secretion that can be easily removed or inhaled. Therapies that can dilate the bronchi as aerosol therapy, bronchodilator aerosolization, or intermittent positive pressure breathing action (IPPB), must be given before postural drainage due to the secretion will flow more easily after tracheo-bronchial branching dilated. The client is instructed to breathe and cough effectively to help remove secretions. Postural drainage is usually performed when the client wakes up, to get rid of secretions that have accumulated throughout the night, and before the break, to improve the quality and quantity of sleep.
7. Collaboration of bronchodilators.
R /: Provision of bronchodilators via inhalation will go directly to the area that experienced the bronchus spasm resulting in faster dilated.
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