Ineffective Airway Clearance related to Bronchiectasis

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.

Nursing Interventions:

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.


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

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

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia is an inflammation of the lung tissue affecting one or both sides of the chest that often occurs as a result of an infection. Infection can be caused by a lot of different micro-organisms – viruses (eg respiratory syncytial virus), bacteria, fungi (eg histoplasmosis) and parasites. In addition to infection, pneumonia can also be caused by corrosive chemicals breathed into the lungs or toxic smoke inhalation from a fire.

Rarely, pneumonia can result from you breathing in something that you are allergic to. This may be related to a hobby or to your employment. The medical term for pneumonia caused by an allergy is extrinsic allergic alveolitis. An example of this condition is farmer’s lung, caused by breathing in the dust from mouldy hay.

Pneumonia is still a common disease affecting around 1 per cent of the adult UK population each year. Many people die from it every year, most commonly women and especially people over the age of 70. The overall death rate due to pneumonia is currently 5 per cent, ie around 1 in 20 people contracting the condition die from it.

Half of all pneumonia cases are caused by bacteria. The bacteria, known as streptococcus pneumoniae is the main cause of the most typical pneumonia.

www.netdoctor.co.uk

Pneumonia Nursing Diagnosis - Ineffective Airway Clearance and Impaired Gas Exchange

Pneumonia Nursing Diagnosis :

1. Ineffective airway clearance related to tracheal bronchial inflammation, increased sputum production is characterized by:

• Changes in frequency, depth of breathing
• Abnormal breath sounds
• Dyspnea, cyanosis
• Effective or ineffective cough with / without sputum production.

Effective airway with the following criteria:

• Cough effective
• Breath of normal
• The sound of breathing clean
• Cyanosis

Nursing Interventions:

Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, breathing shallow and asymmetrical chest movements frequently occur
because of discomfort.

Auscultation of lung area, record the time there's an area of ​​decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of ​​consolidation with fluid.

Let the effective coughing techniques
Rational: cough is a natural cleaning mechanism for maintaining airway patent.

Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors
unable to perform effectively because of cough or a decreased level of consciousness.

Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions

Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.

2. Impaired gas exchange related to the oxygen-carrying blood disorder, characterized by impaired oxygen delivery:

• Dyspnea, cyanosis
• Tachycardia
• Nervous / mental changes
• Hypoxia

Nursing Intervention:
Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.

Observation of the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.

Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.

Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.

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

Nursing Diagnosis Ineffective Airway Clearance

Ineffective Airway Clearance

• ( )Actual
• ( )Potential

Related To :

• Atrificial airway
• Excessive or thick secretions
• Inability to cough effectively
• Infection
• Obstruction/restriction
• Pain
• Other

As evidenced by :
Major:

• Ineffective cough.
• Inability to remove airway secretions.

Minor:

• Abnormal breath sounds.
• Abnormal respiratory rate, rythm, depth.

Plan and Outcome

The patient will:

• Maintain patent airway A.E.B.:
  • Clear breath sounds or breath sounds consistent with own baseline.
  • Respirations easy and un-labored.
  • Normal resp. rate.
• Other:

Nursing Interventions

• Assess respiratory rate, depth, rythm, effort, and breath sounds q ___ hours.
• Position: HOB elevated ___ degrees.
• Promote optimum level of activity for best possible lung expansion :
  • Ambulate q ___ for ___ min.
  • Chair q ___ for ___ min.
  • Turn/reposition q ___.
• Suction q ___ hours (and prn) per:
  • Nasal
  • Oral
  • Tracheal
• Encourage fluids when indicated.
• Other:________________

Patient/Significant other signature



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