• 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

I. Pathophysiology

• Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space
• Intrathoracic pressure changes induced by increased pleural space volumes and reduced lung capacity, causing respiratory distress and gas exchange problems and producing tension on mediastinal structures that can impede cardiac and systemic circulation
• Complications include hypoxemia, respiratory failure, and cardiac arrest.

II. Classification

• Primary spontaneous pneumothorax
• Secondary spontaneous pneumothorax
• Iatrogenic pneumothorax
• Traumatic pneumothorax

III. Etiology

• Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
• Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
• Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus
• Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries

IV. Statistics

(American Lung Association, June 2005)

• Morbidity: Primary spontaneous pneumothorax affects 9,000 persons per year and is more common in tall, thin  men between 20 and 40 years of age.
• Recurrence rate: Is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.
• Mortality: Rate is 15% for those with secondary pneumothorax.

Care Setting

Client is treated in inpatient medical or surgical unit.

Nursing Priorities

1. Promote or maintain lung reexpansion for adequate oxygenation and ventilation.
2. Minimize or prevent complications.
3. Reduce discomfort and pain.
4. Provide information about disease process, treatment regimen, and prognosis.

Discharge Goals

1. Adequate ventilation and oxygenation maintained.
2. Complications prevented or resolved.
3. Pain absent or controlled.
4. Disease process, prognosis, and therapy needs understood.
5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Ineffective Breathing Pattern

May be related to

• Decreased lung expansion due to air or fluid accumulation
• Musculoskeletal impairment
• Pain and anxiety
• Inflammatory process
• Possibly evidenced by
• Dyspnea, tachypnea
• Changes in depth or equality of respirations; altered chest excursion
• Use of accessory muscles, nasal flaring
• Cyanosis, abnormal ABGs

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

• Establish a normal and effective respiratory pattern with ABGs within client’s normal range.
• Be free of cyanosis and other signs or symptoms of hypoxia.

Actions/Interventions

Respiratory Monitoring

Independent

• Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
• Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
• Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
• Auscultate breath sounds.
• Note chest excursion and position of trachea.
• Assess fremitus.
• Ventilation Assistance
• Assist client with splinting painful area when coughing, or during deep breathing.
• Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible.
• Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.

Tube Care: Chest

• Once chest tube is inserted:
• Determine if dry seal chest drain or water seal system is used.
• If water seal system is used:
  • Check suction control chamber for correct amount of suction, as determined by water level, wall or table regulator, at correct setting.
  • Check fluid level in water-seal chamber; maintain at prescribed level.
  • Observe for bubbling in water-seal chamber.
  • Evaluate for abnormal or continuous water-seal chamber bubbling.
  • Determine location of air leak (client or system centered) by clamping thoracic catheter just distal to exit from chest.
  • Place petrolatum gauze or other appropriate material around the insertion as indicated.
  • Clamp tubing in stepwise fashion downward toward drainage unit if air leak continues.
  • Seal drainage tubing connection sites securely with lengthwise tape or bands according to established policy.
  • Monitor water-seal chamber “tidaling.” Note whether change is transient or permanent.
  • Position drainage system tubing for optimal function; for example, shorten tubing or coil extra tubing on bed, making sure tubing is not kinked or hanging below entrance to drainage container. Drain accumulated fluid as necessary.
  • Note character and amount of chest tube drainage, whether tube is warm and full of blood and whether bloody fluid level in water-seal bottle is rising.
  • Evaluate need for gentle “milking” of chest tube per protocol. If thoracic catheter is disconnected or dislodged:
    • Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once.
  • After thoracic catheter is removed:
    • Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage.

Collaborative

• Assist with and prepare for reinflation procedures; for example, simple aspiration, Heimlich valve, and chest tube placement with chest tube drainage unit (CDU).
• Obtain postplacement x-rays and review serial chest x-rays.

Ventilation Assistance

• Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
• Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated.
• Administer analgesics and sedatives, as indicated.

Source 1

Pneumothorax/Hemothorax Nursing Care Plan: Ineffective Breathing Pattern Original source at: Nurseslabs

Pneumonia

INCIDENCES

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.

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Signs and Symptoms of Pneumonia [From Wikipedia

1 Ineffective Airway Clearance

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.

5 Pneumonia Nursing Care Plans Original source at: Nurseslabs

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.

6 Pleural Effusion Nursing Care Plans Original source at: Nurseslabs

Bronchial 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