• An increase in the size and number of submucous glands in the large bronchi which causes increase mucus production
• An increased number of globlet cells, which also secrete mucus
• Impaired ciliary function, which reduces mucus clearance

1 Ineffective Airway Clearance

COPD is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway.

2 Ineffective Breathing Pattern

The presence of microorganisms in the lungs causes body to increase the secretory activity of goblet cells to get rid of the invading organism but the mechanism is not enough which allows the stasis of mucus secretion leading to ineffective breathing pattern.

3 Impaired Gas Exchange

The disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection leading to inflammation and accumulation of secretions. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively.

4 Sleep Pattern Disturbance

COPD patients need a comfortable position such as the High-Fowler’s position during sleeping in order to promote lung expansion. Lying flat on bed promotes the occurrence of DOB and makes the patient uncomfortable due to the impaired alveolar ventilation which the body processes at night can’t be controlled

5 Risk for Spread of Infection

Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection

Other nursing diagnoses:

• 6 High risk for suffocation
• 7 High risk for aspiration
• 8 Anxiety RT acute breathing difficulties
• 9 Activity Intolerance RT inadequate oxygenation
• 10 Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea (for empysema)

10 Chronic Obstructive Pulmonary Disease: Bronchitis Nursing Care Plans Original source at: Nurseslabs

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure (Joyce M. Black, 2008).

1. Decreased Cardiac Output

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

10 Congestive Heart Failure Nursing Care Plans Original source at: Nurseslabs

Pneumonia is the inflammation of the lung caused by bacteria in which the air sacs become filled with inflammatory cells and the lung becomes solid. The symptoms include those of any infection (fever, malaise, headache, etc.,) together with cough and chest pain.

It is estimated that, worldwide, some 4 million children under five years of age, die each year from acute respiratory infection (ARI) with the most of these deaths caused by pneumonia in developing countries.

In 1989, when the program for Control Acute Respiratory Infections (CARI) of the Philippines was launched, the death toll from pneumonia among children under the age of five years was 25,000. The latest statistics (2006) disclosed that almost 60 out of 1000 children under five children suffer from pneumonia and five in every 11,000 die from the disease. The Department of Health believes that if health workers used a standard method of detecting and managing ARI’s specially pneumonia, infant deaths could be cut by half, saving 50,000 lives a year. Pneumonia can be categorized by type of infiltrate: lobar pneumonia and bronchopneumonia.

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1 Ineffective Airway Clearnace

Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways.

6 More Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/more-bronchopneumonia-nursing-care-plans/feed/ 2 http://nurseslabs.com/6-pleural-effusion-nursing-care-plans/ http://nurseslabs.com/6-pleural-effusion-nursing-care-plans/#comments Thu, 05 Jan 2012 07:40:20 +0000 NursesLabs http://nurseslabs.com/?p=885 Pleural effusion is an accumulation of fluid in the pleural space. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.

6 Pleural Effusion Nursing Care Plans Original source at: Nurseslabs

]]> Pleural effusion is an accumulation of fluid in the pleural space. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

• Increased systemic hydrostatic pressure (e.g., heart failure)
• Reduced capillary oncotic pressure (e.g., liver or renal failure)
• Increased capillary permeability (e.g., infection or trauma)
• Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

 

1 Ineffective Breathing Pattern

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

Assessment	Nursing Diagnosis	Planning	Nursing Inter­ventions	Rationale	Expected Outcome
Subjective: Dyspnea Objectives: The patient manifested the following: Tachypnea Presence of crackles on both lung fields upon auscultation use of accessory muscles RR of 28 The patient may manifest the following: Cyanosis Orthopnea Diaphoresis	Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea	Short Term:After 3 hours of nursing interventions the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern. Long term: After 1 to 2 days of nursing interventions, the patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.	- Establish rapport- Monitor and record vital signs - Assess breath sounds, respiratory rate, depth and rhythm - Elevate head of the pt. - Provide relaxing environment - Administer supplemental oxygen as ordered -Assisst client in the use of relaxation technique - Administer prescribed medications as ordered -Maximize respiratory effort with good posture and effective use if accessory muscles. -Encourage adequate rest periods between activities	- To gain pt/ SO’s trust and cooperation- To obtain baseline data - To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia - To promote lung expansion - To promote adequate rest periods to limit fatigue - To maximize oxygen available for cellular uptake -To provide relief of causative factors - For the pharmacological management of the patient’s condition -To promote wellness - to limit fatigue	Short Term:The patient shall have demonstrated appropriate coping behaviors and methods to improve breathing pattern. Long term: The patient shall have applied techniques that improved breathing pattern and be free from signs and symptoms of respiratory distress AEB respiratory rate within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing.

6 Pleural Effusion Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/6-pleural-effusion-nursing-care-plans/feed/ 0 http://nurseslabs.com/bronchial-asthma-nursing-care-plans/ http://nurseslabs.com/bronchial-asthma-nursing-care-plans/#comments Thu, 05 Jan 2012 02:00:44 +0000 NursesLabs http://nurseslabs.com/?p=232 Nursing Care Plans for Bronchial Asthma or BAIAE, nursing management, respiratory function tests, nursing responsibilities, and assessment

5 Bronchial Asthma Nursing Care Plans Original source at: Nurseslabs

]]> Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways.
Bronchial asthma is the more correct name for the common form of asthma.

What do you think is the nursing goal for patient’s with bronchial asthma, and what is that one-most nursing diagnosis that pops to your head when you hear asthma?

 

This post contains 5 bronchial asthma nursing care plans. 

1 Ineffective Airway Clearance

The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to fluid leakage from the lung vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

Asthma- Ineffective- Airway- Clearance

5 Bronchial Asthma Nursing Care Plans Original source at: Nurseslabs

]]> http://nurseslabs.com/bronchial-asthma-nursing-care-plans/feed/ 0 http://nurseslabs.com/community-acquired-pneumonia-nursing-care-plans/ http://nurseslabs.com/community-acquired-pneumonia-nursing-care-plans/#comments Wed, 21 Dec 2011 13:16:19 +0000 NursesLabs http://nurseslabs.com/?p=329 Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the [...]

Community Acquired Pneumonia Nursing Care Plans Original source at: Nurseslabs

]]> Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively (Wikipedia).

Community acquired pneumonia is a type of pneumonia that occurred within 48 hours after admission. The nursing goal is the same as pneumonia, combat infection, provide supportive treatment, establishing effective airway and monitor for signs of respiratory distress.

Impaired Gas Exchange

Pneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites and viruses. As the lung parenchyma and alveoli of the lungs are inflamed it impairs gas exchange due to the alterations in the alveoli which is the site for actual gas exchange.

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(See? Even the scientific explanation is like from a pneumonia. Nursing care plans for pneumonia can be found here)

Community Acquired Pneumonia Nursing Care Plans Original source at: Nurseslabs

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