Nurseslabs » ineffective airway clearance

Ineffective Airway Clearance — COPD Nursing Care Plans

Nurseslabs — Sat, 28 Apr 2012 19:58:52 +0000

NURSING DIAGNOSIS: Ineffective Airway Clearance

May be related to

Bronchospasm
Increased production of secretions; retained secretions; thick, viscous secretions
Decreased energy/fatigue

Possibly evidenced by

Statement of difficulty breathing
Changes in depth/rate of respirations, use of accessory muscles
Abnormal breath sounds, e.g., wheezes, rhonchi, crackles
Cough (persistent), with/without sputum production

Desired Outcomes

Maintain patent airway with breath sounds clear/clearing.
Demonstrate behaviors to improve airway clearance, e.g., cough effectively and expectorate secretions.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Auscultate breath sounds. Note adventitious breath sounds, e.g., wheezes, crackles, rhonchi.	Some degree of bronchospasm is present with obstructions in airway and may/may not be manifested in adventitious breath sounds, e.g., scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).
Assess/monitor respiratory rate. Note inspiratory/expiratory ratio.	Tachypnea is usually present to some degree and may be pronounced on admission or during stress/concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.
Note presence/degree of dyspnea, e.g., reports of “air hunger,” restlessness, anxiety, respiratory distress, use of accessory muscles. Use 0–10 scale or American Thoracic Society’s “Grade of Breathlessness Scale” to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.	Respiratory dysfunction is variable depending on the underlying process, e.g., infection, allergic reaction, and the stage of chronicity in a patient with established COPD. Note: Using a 0–10 scale to rate dyspnea aids in quantifying and tracking changes in respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus.
Assist patient to assume position of comfort, e.g., elevate head of bed, have patient lean on overbed table or sit on edge of bed.	Elevation of the head of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms/legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.
Keep environmental pollution to a minimum, e.g., dust, smoke, and feather pillows, according to individual situation.	Precipitators of allergic type of respiratory reactions that can trigger/exacerbate onset of acute episode.
Encourage/assist with abdominal or pursed-lip breathing exercises.	Provides patient with some means to cope with/control dyspnea and reduce air-trapping.
Observe characteristics of cough, e.g., persistent, hacking, moist. Assist with measures to improve effectiveness of cough effort.	Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.
Increase fluid intake to 3000 mL/day within cardiac tolerance. Provide warm/tepid liquids. Recommend intakeof fluids between, instead of during, meals.	Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm.
Monitor/graph serial ABGs, pulse oximetry, chest x-ray.	Establishes baseline for monitoring progression/regression of disease process and complications. Note: Pulse oximetry readings detect changes in saturation as they are happening, helping to identify trends before patient is symptomatic. However, studies have shown that the accuracy of pulse oximetry may be questioned if patient has severe peripheral vasoconstriction.

Ineffective Airway Clearance — COPD Nursing Care Plans Original source at: Nurseslabs

Ineffective Airway Clearance — Pneumonia Nursing Care Plans

Nurseslabs — Tue, 27 Mar 2012 13:02:34 +0000

Nursing Diagnosis: Airway Clearance, ineffective

May be related to

Tracheal bronchial inflammation, edema formation, increased sputum production
Pleuritic pain
Decreased energy, fatigue

Possibly evidenced by

Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles
Dyspnea, cyanosis
Cough, effective or ineffective; with/without sputum production

Desired Outcomes

Identify/demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.

Nursing Interventions	Rationale
Assess rate/depth of respirations and chest movement.	Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.
Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds, e.g., crackles, wheezes.	Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction.
Elevate head of bed, change position frequently.	Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
Assist patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position.	Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.
Suction as indicated (e.g., frequent or sustained cough, adventitious breath sounds, desaturation related to airway secretions).	Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough or decreased level of consciousness.
Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids.	Fluids (especially warm liquids) aid in mobilization and expectoration of secretions.
Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy, e.g., incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.	Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations.
Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.	Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/depress respirations.
Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification.	Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.
Monitor serial chest x-rays, ABGs, pulse oximetry readings.	Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.
Assist with bronchoscopy/thoracentesis, if indicated.	Occasionally needed to remove mucous plugs, drain purulent secretions, and/or prevent atelectasis.

Ineffective Airway Clearance — Pneumonia Nursing Care Plans Original source at: Nurseslabs

NANDA Nursing Diagnosis List

bobbyRN — Mon, 20 Feb 2012 15:08:18 +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 — Sat, 11 Feb 2012 08:31:55 +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 - Bronchial Asthma Nursing Care Plans

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

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

Planning

Nursing Interventions

Rationale

Expected Outcome

S:O: 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

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 RT Retained Secretions

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

Planning

NursingInterventions

Rationale

Expected Outcome

Reports of dyspnea

O: 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

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 RT Altered Oxygen Balance

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

Planning

NursingInterventions

Rationale

Expected Outcome

S:O: 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

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 RT Difficulty of Breathing

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

Planning

Nursing
Interventions

Rationale

Expected Outcome

S:
O:The patient may manifest the ffg.:

irritability
restlessness
lethargy
changes in posture
difficulty of breathing which worsens at night

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 RT Stasis of Secrections & Decreased Ciliary Action

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

Planning

NursingInterventions

Rationale

Expected Outcome

S:O:The patient may manifest:

Body temperature above normal range
dehydration
increase WBC count
presence of increase mucus production

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 (HF) or Congestive Heart Failure (CHF) 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).

Here are 10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output - Congestive Heart Failure Nursing Care Plans

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

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

Assessment

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

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 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 Clearance

NDx: Ineffective airway clearance r/t accumulation of tracheobronchial secretions

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

Planning

Nursing Interventions

Rationale

Expected Outcome

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

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 Bronchopneumonia Nursing Care Plans Original source at: Nurseslabs

5 Pneumonia Nursing Care Plans

Nurseslabs — Thu, 12 Jan 2012 14:49:32 +0000

Pneumonia is an inflammatory illness of the lung. It is often described as lung parenchyma or alveolar inflammation leading to abnormal alveolar filling with fluid. Pneumonia can result from a variety of causes, including infection with microorganisms like bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs.

Incidences of Pneumonia

Pneumonia is a common illness in all parts of the world in all age groups. Majority of deaths occur in the newborn period in children, with over two million deaths a year worldwide.

The World Health Organization estimates that one out of three newborn infant deaths is due to pneumonia.
It kills more children than any other illness, accounting for 19% of all under-five deaths.
According to the National Statistical Coordination Board of the Philippines, there are 776,562 of pneumonia in the country in 2004 alone. This could be an implication that pneumonia is one of the leading causes of morbidity and mortality in the country.
World Health Organization notes Invasive Pneumococcal Disease deaths at 1.6 million people each year.
Of these, 700,000 to one million are children under five years old and over 90 percent of these deaths occur in developing countries.
Pneumonia is a top killer in India,China,Nigeria,Pakistan,Bangladesh,Indonesia, and Brazil.

Additional & Updated Nursing Care Plans for Pneumonia

1. Ineffective Airway Clearance

NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia.

The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

ASSESSMENT

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EXPECTED OUTCOMES

With unproductive cough
With wheezes and crackles auscultated on left lower lungfield.
Presence of clear watery discharge from her nose
Restlessness
Irritability

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration will improve and difficulty of breathing will be relieved. Long Term:

After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.

Establish rapport to patient and SO
Assess patient’s condition
Monitor and record V/S
Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds
Assist patient to change position every 30 minutes
Elevate head of bed and align head in the middle
Provide health teachings regarding effective coughing and deep breathing exercise.
Encourage to increase fluid intake.
Encourage steam inhalation
Administer meds as ordered

To gain the trust and cooperation
To know and determine patient’s needs
To establish base line data
To identify areas of consolidation and determine possible bronchospasm or obstruction.
To mobilize secretions
To facilitate breathing
To expel the mucous
To liquefy secretions
To moisten secretions and alleviate congestion
To reduce bronchospasm and mobilize secretion

Short Term: After 3-4 hours of nursing interventions, the patient’s respiration shall have improved and difficulty of breathing shall have been relieved.

Long Term:

After 3 – 4 days of nursing interventions, the patient will have been able to maintain a patent airway.

5 Pneumonia Nursing Care Plans Original source at: Nurseslabs