Ncp Ineffective Airway

Far Eastern University Institute of Nursing Nursing Care Plan Cues S: productive cough for 2 week difficulty of breathing hemoptysis O: (+) crackles RR=32cpm Productive cough Difficulty vocalizing

Analysis Bronchiectasis is a disease state defined by localized, irreversible dilation of part of the bronchial tree. It is classified as an obstructive lung disease, along with emphysema, bronchitis and cystic fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired

Nursing Diagnosis Ineffective airway clearance related to bronchiectasis secondary to pulmonary tuberculosis

Goal and Objectives Goal: After 1 week of nursing intervention, the client will have patent airway.

Interventions

Rationale

Objectives: After 8 hours of nursing intervention, the client will be able to: 1.to be in a semi-fowler’s position

Position the client in a semifowler’s position

To maintain an open airway even when at rest

2. state in her own words what deep breathing is

Explain to the client what deep breathing is

Deep breathing promotes oxygenation before

Outcome Evaluation After 1 week of nursing intervention, the client was able to have patent airway.

clearance of secretions. Bronchiectasis is associated with a wide range of disorders, but it usually results from necrotizing bacterial infections, such as infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis.

controlled coughing

3. state in her own words the mportance of deep breathing

Discuss with the client the importance of deep breathing

4. demonstrate proper deep breathing

Demonstrate to the client proper deep breathing

5. state in her own words what coughing exercise is

Explain to the client what coughing exercise is

5. state in her own words the importance of coughing exercises

Discuss with the client the importance of coughing exercises

Controlled coughing is accomplished by closure of the glottis and the expulsion of air from the lungs by the work of abdominal and chest muscles

6. demonstrate proper coughing exercises

Demonstrate to the client the proper coughing exercises

(Fundamentals of Nursing by Kozier and Erb 7th edition page 1327)

(Fundamentals of Nursing by Kozier and Erb 7th edition page 1327)

7. explain the importance of fluid hydration

Explain to the client the importance of fluid hydration

Adequate fluid intake enhances liquefaction of pulmonary secretion and facilitates expectoration of mucus. (Fundamentals of Nursing by Kozier and Erb 7th edition page 1327)

8. explain the importance of compliance to medications

Explain to the client the importance of compliance to medications

Strict compliance to medication will facilitate recovery

Administer medications as ordered

(Pharmacology 8th edition)