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10 Chronic Obstructive Pulmonary Disease: Bronchitis Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:54 +0000

Chronic Obstructive Bronchitis is an inflammation of the bronchi (chronic obstructive bronchitis) causes increase mucus production and chronic cough. The clinical manifestations of Chronic Bronchitis continue for at least 3 months of the year for 2 consecutive years. Chronic bronchitis is also known the blue bloater. It is characterized by the following:

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.

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Expected Outcome

S:ÆO: The may patient manifest the ffg.:>with wheezes/crackles upon auscultation on the BLF

>with subcostal retraction

>with nasal flaring

>presence of non-productive cough

>increase RR above normal range

Ineffective airway clearance related to retained and excessive secretions and ineffective coughing

Short term:After 4-5 hours of nursing interventions the patient will demonstrate effective clearing of secretions.Long term:After 2 days of nursing interventions, the patient will maintain effective airway clearance.

>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Position head midline with flexion on appropriate for age/condition

>Elevate HOB

>Observe S/Sx of infections

>Auscultate breath sounds & assess air mov’t

>Instruct the patient to increase fluid intake

>Demonstrate effective coughing and deep-breathing techniques.

>Keep back dry

>Turn the patient q 2 hours

>Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage.

>Administer bronchodilators

if prescribed.

>To gain trust and active participation>To know the condition of the pt>To have a baseline data.>To gain or maintain open airway

>To decrease pressure on the diaphragm and enhancing drainage

>To identify infectious process

>To ascertain status & note progress

>To help to liquefy secretions.

>To maximize effort

>To prevent further complications

>To prevent possible aspirations

>These techniques will prevent possible aspirations and prevent any untoward complications

>More aggressive measures to maintain airway patency.

Short term:The patient shall have demonstrated effective clearing of secretions.Long term:The patient shall have maintained effective airway clearance.

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.

Assessment

Nursing Dx

Planning

NursingInterventions

Rationale

Expected Outcome

S: Reports of dyspneaO: The patient may manifest the manifest the ffg.:> with wheezes /crackles upon auscultation on BLF> increase RR above normal range

>presence of productive cough

>use of accessory muscle when breathing

>presence of nasal flaring and retractions

Ineffective breathing pattern related to retained mucus secretions

Short term:After 4-5 hours of nursing interventions the patient will improve breathing pattern.Long term:After 2 days of nursing interventions the patient will maintain a respiratory rate within normal limits.

>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S especially RR>Provide rest periods

>Place pt in semi-fowlers position

>Increase fluid intake

>Keep patient back dry

>Change position every 2 hours

>Perform CPT

>Place a pillow when the client is sleeping

>Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate

>Maintain a patent airway, suctioning of secretions may be done as ordered

>Provide respiratory support. Oxygen inhalation is provided per doctor’s order

>Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired.

>To gain trust and active participation>To know the condition of the pt>To have a baseline data.>To reduce fatigue and obtain rest

>To have a maximum lung expansion

>To liquefy secretions

>To avoid stasis of secretions and avoid further complication

>To facilitate secretion mov’t and drainage

>To loosen secretion

>To provide adequate lung expansion while sleeping.

>To promote physiological ease of maximal inspiration

>To remove secretions that obstructs the airway

>To aid in relieving patient from dyspnea

>To promote deeper respirations and cough

Short term:The patient shall have improved breathing pattern.Long term:The patient shall have maintained a respiratory rate within normal limits.

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.

Assessment

Nursing Dx

Planning

NursingInterventions

Rationale

Expected Outcome

S:ÆO: The patient may manifest the ffg.:>Appearance of bluish extremities when in cough (cyanosis), lips>Lethargy

>Restlessness

>Hypercapnea

>Hypoxemia

>Abnormal rate, rhythm, depth of breathing

>Diaphoresis

Impaired gas exchange related to altered oxygen

Short term:After 4-5 hours of nursing interventions the patient will improve ventilation and adequate oxygenation of tissuesLong term:After 2 days of nursing interventions the patient will minimize or totally be free of symptoms of respiratory distress.

>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Monitor level of consciousness or mental status

>Assist the client into the High-Fowlers position

>Increase patient’s fluid intake

>Encourage expectoration

>Encourage frequent position changes

>Encourage adequate rest & limit activities to within client tolerance

>Promote calm/restful environments

>Administer supplemental oxygen judiciously as indicated

>Administer meds as indicated such as bronchodilators

>To gain trustand active participation>To know the condition of the pt>To have a baseline data.

>Restlessness,

anxiety,

confusion, somnolence are common manifestation of hypoxia and hypoxemia.

>The upright position allows full lung excursion and enhances air exchange

>To help liquefy secretions

>To eliminate thick, tenacious, copious secretions which contribute for the impairment of gas exchange.

>To promote drainage of secretions

>Helps limit oxygen

needs/consumption

>To correct/improve existing deficiencies

>May correct or prevent worsening of hypoxia.

>To treat the underlying condition

Short term:The patient shall have improved ventilation and adequate oxygenation of tissuesLong term:The patient shall have minimized or totally be free of symptoms of respiratory distress.

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

Assessment

Nursing Dx

Planning

NursingInterventions

Rationale

Expected Outcome

S:ÆO: The patient may manifest the ffg.:>irritability>restlessness

>lethargy

>changes in posture

>difficulty of breathing which worsens at night

Sleep pattern disturbance related to difficulty of breathing

Short term:After 4-5 hours of nursing interventions the patient will identify individually appropriate interventions to promote sleep.Long term:After 2 days of nursing interventions, the patient will be able to report improvements in sleep/rest pattern.

>Establish rapport to the pt. and SO>Assess the patient condition>Monitor and record V/S>Monitor level of consciousness or mental status

>Promote comfort measures such as back rub and change in position as necessary

>Observe provision of emotional support

>Provide quiet environment.

>Increase patient’s fluid intake

>Encourage expectoration

>Limit the fluid intake in evening if nocturia is a problem

>Obtain feedback from SO regarding usual bedtime, rituals/routines

>Provide safety for patient sleep time safety

>Recommend midmorning nap if one required

>Administer pain medication as ordered.

>To gain trust and active participation>To know the condition of the pt>To have a baseline data>Restlessness, anxiety,

confusion, somnolence are common manifestation of hypoxia and hypoxemia.

>To provide non pharmagcologic management

>Lack of knowledge and problems, relationships may create tension. Interfering with sleep routines based on adult schedules may not meet child’s needs.

>To promote an environment conducive to sleep.

>To help liquefy secretions

>To eliminate thick, tenacious, copious secretions which contribute for the DOB

>To reduce need for nighttime elimination

>To determine usual sleep patterns & provide comparative baseline

>To promote comfort/safety

>Napping esp. in the afternoon can disrupt normal sleep pattern

>To relieve discomfort and take maximum advantage of sedative effect

Short term:The patient shall have identified individually appropriate interventions to promote sleepLong term:The patient shall have reported improvements in pt.’s sleep/rest

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

Assessment

Nursing Dx

Planning

NursingInterventions

Rationale

Expected Outcome

S:ÆO: The patient may manifest:>Body temperature above normal range>dehydration

>increase WBC count

>presence of increase mucus production

Risk for spread of infection related to stasis of secretions and decreased ciliary action.

Short term:After 4-5 hours of nursing interventions the patient will identify interventions to prevent and/or reduce the risk of infectionLong term:After 2 days of nursing interventions the patient will have minimize or totally be free from the risk of infection.

>Establish rapport to the pt. and SO>Assess the patient condition>Monitor & record V/S>Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake

>Turn the patient q 2 hours

>Encourage increase fluid intake

>Stress the importance of handwashing to SO’s

>Teach the SO’s how to care for and clean respiratory equipment

>Teach the SO’s the manifestations of pulmonary infections (change in color of sputum, fever, chills) , self-care and when to call the physician

>Recommend rinsing mouth with water

>Administer antimicrobial such as cefuroxime as indicated.

>To gain trust and active participation>To know the condition of the pt>To have a baseline data and fever may be present because of infection and/or dehydration>These activities promote mobilization and expectoration of secretions to reduce the risk of developing pulmonary infection.

>To facilitate secretion mov’t and drainage

>To liquefy secretions

>Handwashing is the primary defense against the spread of infection

>Water in respiratory equipment is a common source of bacterial growth

>Early recognition of manifestations can lead to a rapid diagnosis.

>To prevent risk of oral candidiasis.

>Given prophylactically to reduce any possible complications

Short term:The shall have identified interventions to prevent and/or reduce the risk of infectionLong term:The patient shall have minimized or totally be free from the risk of 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

10 Congestive Heart Failure Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:53 +0000

Heart failure is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

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

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Evaluation

Subjective:(none)

Objectives:

The patient manifested the following:

with pale conjunctiva, nail beds and buccal mucosa
irregular rhythm of pulse
bradycardic
pulse rate of 34 beats/min
generalized weakness

Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Short Term:After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart.Long Term:After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.

Assess for abnormal heart and lung sounds.

Monitor blood pressure and pulse.

Assess mental status and level of consciousness.

Assess patient’s skin temperature and peripheral pulses.

Monitor results of laboratory and diagnostic tests.

Monitor oxygen saturation and ABGs.

Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.

Implement strategies to treat fluid and electrolyte imbalances.

Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.

Encourage periods of rest and assist with all activities.

Assist the patient in assuming a high Fowler’s position.

Teach patient the pathophysiology of disease, medications

Reposition patient every 2 hours

Instruct patient to get adequate bed rest and sleep

Instruct the SO not to leave the client unattended
Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.

Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism.

The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.

Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate.

Results of the test provide clues to the status of the disease and response to treatments.

Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood

Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance.

Decreases the risk for development of cardiac output due to imbalances.

Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output.

Reduces cardiac workload and minimizes myocardial oxygen consumption.

Allows for better chest expansion, thereby improving pulmonary capacity.

Provides the patient with needed information for management of disease and for compliance.

To prevent occurrence of bed sores

To promote relaxation to the body

To ensure safety and reduce risk for falls that may lead to injury

Short Term:After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart.Long Term:After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

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

6 More Bronchopneumonia Nursing Care Plans

NursesLabs — Sat, 21 Jan 2012 09:16:19 +0000

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.

View our gallery of nursing care plans

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.

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Expected Outcome

S>(none)

>Restlessness with nasal flaring

> With rales on both lung fields

> warm, flushed skin

>minimal colorless nasal secretions

>tachypnea AEB RR=53bpm

>DOB

>tachycardia

>irritability

>chest indrawing

>cough

>cyanosis

>noisy breathing

>pallor

>changes in RR and rhythm

>risk for infection

>orthopnea

>tachypnea

Ineffective airway clearance r/t accumulation of tracheobronchial secretions

SHORT TERM:

After 3-4 hours of NI, pt.’s SO will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and RR improve

LONG TERM:

After 2-3 days of NI, pt. will be able to establish and maintain airway patency.

> Monitor and record vital signs

> Assess patient’s condition.

> Elevate head of bed and encourage frequent position changes.

> Keep back dry and loosen clothing

>Auscultate breath sounds and assess air movement

>Monitor child for feeding intolerance and abdominal distention

> Instruct the SO to provide an increased fluid intake for the child

> Instruct the SO to provide

adequate rest periods for the child

> Give expectorants and bronchodilators as ordered.

> Administer oxygen therapy and other medications as ordered.

> To obtain baseline data

> To know the patient’s general condition

> To promote maximal inspiration, enhance expectoration of secretions in order to improve ventilation

> To promote comfort and adequate ventilation

> To ascertain status and to note progress

> To avoid compromising the airway

> To help liquefy the secretions

> Rest will prevent fatigue and decrease oxygen demands for metabolic demands

> To further mobilize secretions

> To clear airway when secretions are blocking the airway

indicated to increase oxygen saturation.

SHORT TERM:

After 3-4 hours of NI, pt. shall have demonstrated improve airway clearance AEB reduction of congestion with breath sounds clear and RR improve

LONG TERM:

After 2-3 days of NI, pt. shall have established and maintained airway patency.

6 More Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

NANDA Nursing Diagnosis List

bobbyRN — Thu, 12 Jan 2012 09:30:32 +0000

Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by the nurses in the nursing process to provide more comprehensive assessment of the client.

Below contains the list of nursing diagnoses approved by NANDA-I.

Health Perception and Management Pattern

Contamination
Disturbed energy field
Effective therapeutic regimen management
Health-seeking behaviors
Ineffective community therapeutic regimen management
Ineffective family therapeutic regimen management
Ineffective health maintenance
Ineffective protection
Ineffective therapeutic regimen management
Noncompliance
Readiness for enhanced immunization status
Readiness for enhanced therapeutic regimen management
Risk for contamination
Risk for falls
Risk for infection
Risk for injury (trauma)
Risk for perioperative positioning injury
Risk for poisoning
Risk for suffocation

Nutritional-Metabolic Pattern

Adult failure to thrive
Deficient blood volume
Effective breastfeeding
Excess fluid volume
Hyperthermia
Hypothermia
Imbalanced nutrition: more than body requirements
Imbalanced nutrition: less than body requirements
Imbalanced nutrition: risk for more than body requirements
Impaired dentition
Impaired oral mucous membrane
Impaired skin integrity
Impaired swallowing
Impaired tissue integrity (specify type)
Ineffective breastfeeding
Ineffective infant feeding pattern
Ineffective thermoregulation
Interrupted breastfeeding
Latex allergy response
Nausea
Readiness for enhanced fluid balance
Readiness for enhanced nutrition
Risk for aspiration
Risk for deficient fluid volume
Risk for imbalanced fluid volume
Risk for imbalanced body temperature
Risk for latex allergy response
Risk for impaired liver function
Risk for impaired skin integrity
Risk for unstable blood glucose

Elimination Pattern

Bowel incontinence
Constipation
Diarrhea
Functional urinary incontinence
Impaired urinary elimination
Overflow urinary incontinence
Perceived constipation
Readiness for enhanced urinary elimination
Reflex urinary incontinence
Risk for constipation
Risk for urge urinary incontinence
Stress urinary incontinence
Total urinary incontinence
Urge urinary incontinence
Urinary retention

Activity-Exercise Pattern

Activity intolerance (specify)
Autonomic dysreflexia
Decreased cardiac output
Decreased intracranial adaptive capacity
Deficient diversional activity
Delayed growth and development
Delayed surgical recovery
Disorganized infant behavior
Dysfunctional ventilatory weaning response
Fatigue
Impaired spontaneous ventilation
Impaired bed mobility
Impaired gas exchange
Impaired home maintenance
Impaired physical mobility
Impaired transfer ability
Impaired walking
Impaired wheelchair mobility
Ineffective airway clearance
Ineffective breathing pattern
Ineffective tissue perfusion (specify)
Readiness for enhanced organized infant behavior
Risk for disproportionate growth
Risk for activity intolerance
Risk for autonomic dysreflexia
Risk for disuse syndrome
Risk for peripheral neurovascular dysfunction
Risk for sudden infant death syndrome
Sedentary lifestyle
Self-care deficit (specify: bathing/hygiene, dressing/grooming, feeding, toileting)
Wandering

Sleep-Rest Pattern

Insomnia
Readiness for enhanced sleep
Sleep deprivation

Cognitive-Perceptual Pattern

Acute confusion
Acute pain
Chronic confusion
Chronic pain
Decisional conflict (specify)
Deficient knowledge (specify)
Disturbed sensory perception (specify)
Disturbed thought process
Impaired environmental interpretation syndrome
Impaired memory
Readiness for enhanced comfort
Readiness for enhanced decision making
Readiness for enhanced knowledge
Risk for acute confusion
Unilateral neglect

Self-Perception and Self-Conception Pattern

Anxiety
Chronic low self-esteem
Death anxiety
Disturbed body image
Disturbed personal identity
Fear
Hopelessness
Powerlessness
Readiness for enhanced hope
Readiness for enhanced power
Readiness for enhanced self-concept
Risk for compromised human dignity
Risk for loneliness
Risk for self-directed violence
Risk for powerlessness
Risk for situational low self-esteem
Situational low self-esteem

Role-Relationship Pattern

Caregiver role strain
Chronic sorrow
Dysfunctional family process: alcoholism
Impaired parenting
Impaired social interaction
Impaired verbal communication
Ineffective role performance
Interrupted family process
Parental role conflict
Readiness for enhanced communication
Readiness for enhanced family processes
Readiness for enhanced parenting
Relocation stress syndrome
Risk for caregiver role strain
Risk for complicated grieving
Risk for impaired parent/child attachment
Risk for impaired parenting
Risk for relocation stress syndrome
Risk for other-directed violence
Social dysfunction

Sexuality-Reproductive

Ineffective sexuality pattern
Rape-trauma syndrome
Rape-trauma syndrome: compound reaction
Rape-trauma syndrime: silent reaction
Sexual dysfunction

Coping-Stress Tolerance Pattern

Compound family coping
Defensive coping
Disabled family coping
Ineffective community coping
Ineffective coping
Ineffective denial
Post-trauma syndrome
Readiness for enhanced community coping
Readiness for enhanced coping
Readiness for enhanced family coping
Risk for self-mutilation
Risk for suicide
Risk for post-trauma syndrome
Risk-prone health behaviors
Self-mutilation
Stress overload

Value-Belief Pattern

Impaired religiosity
Moral distress
Readiness for enhanced religiosity
Readiness for enhanced spiritual well-being
Risk for impaired religiosity
Risk for spiritual distress
Spiritual distress

These were modified by Marjory Gordon on 2007, with permission.

NANDA Nursing Diagnosis List Original source at: Nurseslabs

5 Bronchial Asthma Nursing Care Plans

NursesLabs — Thu, 05 Jan 2012 02:00:44 +0000

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