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Ineffective airway clearance - NCP for Bronchitis

 |  in Nursing Care Plan at  4:44 PM
Nursing Care Plan for Bronchitis - Ineffective airway clearance

Respiration is gas exchange, namely oxygen (O²) needed by the body for the metabolism of cells and carbon dioxide (CO²) generated from the metabolism excreted from the body through the lungs. Respiration is breathing air from outside events containing oxygen and exhale air that contains a lot of carbon dioxide out of the body.

Ineffective airway clearance - NCP for Bronchitis
The respiratory system is an organ system that serves to take O2 from the atmosphere into the body's cells for transporting CO2 produced by the cells of the body back into the atmosphere. Respiratory organs also serve to talk and play a role in the production of acid-base balance, the body's defense against foreign substances, and hormonal regulation of blood pressure. Respiration is gas exchange between the individual and the environment or the entire process of gas exchange between the atmospheric air and blood and the blood to the body's cells (Syaifuddin, 2002).

The respiratory system is basically formed by the respiratory tract and lungs along with the wrapping (pleura) and chest cavity are protected. In the chest cavity there is also the heart. Chest cavity separated by the abdominal cavity, by the diaphragm. Airway through which the air is the nose, pharynx, larynx, trachea, bronchi, bronchioles and alveoli.

Bronchitis is an inflammation of the bronchi. Bronchitis can be acute or chronic (Irma Somantri, 2009).

Bronchitis is an inflammation of the bronchioles, bronchi, and trachea by various causes. Bronchitis usually more often caused by viruses such as rhinovirus, respiratory syncitial virus (RSV), influenza virus, parainfluenza virus, and coxsackie virus (Arif Muttaqin, 2008).

Bronchitis is an inflammation of the bronchi in the lower respiratory tract. This disease can be caused by bacteria, viruses, or exposure to inhaled irritants (Brunner & Suddarth, 2002).

Chronic bronchitis can be experienced by everyone without any distinction. Frequency morbidity of chronic bronchitis is more frequent in men than women. It's just that until now no definite comparative figures. Age sufferers of chronic bronchitis is more common in the over 50 years (Suparyanto, 2010).

According to Robert L. Wilkins and James B. Dexter in the book Respiratory Diseases: Principles of Patient Care, Chronic bronchitis is one of lung disease in which the patient has a chronic productive cough associated with bronchial inflammation. Before known to suffer from chronic bronchitis, initially patients who experienced a long and productive cough is usually diagnosed by a physician experienced tuberculosis, lung cancer, and congestive heart failure (Puspitasari, 2009).

Chronic bronchitis is often equated with emphysema, even though they are different. Both of these diseases are often found in patients with Chronic Obstructive Pulmonary Disease (COPD). COPD twice in men, more than women, because men are expected heavier smokers than women, but the incidence in women has increased and stabilized in men (Price, 1992).

Nursing Diagnosis for Bronchitis : Ineffective airway clearance related to the increased production of secretions

Goal: The client does not feel shortness of breath and no sputum.

  • Maintain a patent airway with breath sounds clean or clear.
  • Shows behavior to improve airway clearance, for example: an effective cough.
Interventions :
  • Assess the respiratory function, breath sounds, rhythm speed.
  • Assess comfortable position for a client.
  • Festive and encourage clients to cough effectively.
  • Giving mucolytics.
  • Collaboration: Give the drug as indicated.
Rationale :
  • Assist their breathing pattern changes.
  • Can facilitate the circulation of breathing in the body.
  • Cough teach effectively so patients independently.
  • To lower airway spasm.
  • Lowering the mucosal edema and smooth muscle spasm.

Impaired Gas Exchange related to Bronchitis

Physical Examination of Urinary Incontinence in the Elderly

 |  in Urinary Incontinence at  10:21 AM

Urinary incontinence is the inability to hold urine. Urinary incontinence is one of the manifestations of the disease are often found in geriatric patients. It is estimated that the prevalence of urinary incontinence ranges between 15-30% of elderly people and 20-30% in geriatric patients who were hospitalized suffered incontinence of urine, and urine incontinence likely to rise 25-30% at the age of 65-74 years.

Urinary incontinence problem is the number of events increased two times higher in women than men. This disorder is more common in women who have given birth than had never given birth (nulliparous).

Changes due to the aging process affects the lower urinary tract. Such changes predispose the elderly to experience incontinence, but does not cause incontinence. So incontinence is not a normal part of the aging process.

The purpose of the initial evaluation is to ensure the existence of urinary incontinence and identify the causes temporary, patients need to be evaluated further, and patients can start treatment without the need for sophisticated tests.

History of the disease should be emphasis on symptoms in detail in order to be determined the type of incontinence, pathophysiology and trigger factors.

1. The length of time and the characteristics of urinary incontinence.
  • The timing and amount of urine when experiencing urinary incontinence and when dry (continental).
  • Fluid intake, type (coffee, cola, tea) and a number.
  • Other symptoms such as nocturia, dysuria, frequency, hematuria and pain.
  • Accompanying events such as coughing, surgery, diabetes, drugs.
  • Changes in the function of the colon or bladder.
2. Treatment of urinary incontinence before and the results

The medical history should pay attention to issues such as diabetes, heart failure, venous insufficiency, cancer, neurological problems, stroke and Parkinson's disease. This includes a history of the urogenital system such as abdominal and pelvic surgery, childbirth, or urinary tract infection. Evaluation of both medicines purchased by prescription or bought over the counter are also important. Diverse drugs is associated with urinary incontinence such as sedative hypnotics, diuretics, anticholinergics, adrenergic and calcium channel blockers. Usually there is a connection to the time between the use of drugs with the onset or worsening of urinary incontinence who have chronic incontinence.

Physical Examination

The goal is to identify the triggers physical examination of urinary incontinence and help establish pathophysiology. In addition to general physical examination should always be carried out, examination of the abdomen, genitalia, rectum, neurological function, and pelvis (in women) is necessary.
  • Abdominal examination must recognize the existence of a full bladder, pain, mass, or a history of surgery.
  • Skin conditions and anatomic abnormalities should be identified when examining genitals.
  • Examination of the rectum is mainly done to obtain the obstipation, and evaluation of sphincter tone, perineal sensation, and reflexes bulbocavernosus. Prostate nodules can be identified at the time of examination of the rectum.
  • Pelvic examination to evaluate mucosal atrophy, atrophic vaginitis, mass, muscle tone, pelvic prolapse, and the cystocele or rectocele.
  • Neurological Evaluation partially obtained during examination of the rectum when the examination sensation perineum, anus tone, and refles bulbocavernosus. Neurological examination also need to evaluate diseases that can be treated as spinal cord compression and Parkinson's disease.
Physical examination should also include an assessment of functional and cognitive status, pay attention to whether the patient is aware of the desire to urinate and using the toilet.

Examination of Urine Incontinence

1. Diagnostic tests in urinary incontinence

According Ouslander, diagnostic tests on the incontinence needs to be done to identify potential factors that lead to incontinence, identifying client needs and determine the type of incontinence.

Measuring residual urine after urination, done by:
After urinating, attach the catheter, urinary catheter out through measured or using ultrasonic inspection of the pelvis, when the rest of the urine more dari100 cc means inadequate emptying of the bladder.

  • Carried out on a clean urine specimen to detect the presence of factors that contribute to the occurrence of urinary incontinence such as hematuria, polyuria, bacteriuria, glycosuria, and proteinuria. Advanced diagnostic tests need to be followed when diagnosed early evaluation is not yet clear. Further tests are:
  • Additional laboratory tests such as urine culture, blood urea nitrogen, creatinine, calcium, glucose cytology.
  • Urodynamic tests: to know the anatomy and function of the lower urinary tract.
  • Urethra pressure test: measuring the pressure in the urethra when at rest and dynamic.
  • Imaging: tests for urinary tract upper and lower parts.

2. Investigations

Simple urodynamic test can be performed without the use of expensive tools. Remnants of urine after urination need is estimated at physical examination. Specific measurements can be performed with ultrasound or urinary catheterization. Leakage of urine when pressure is applied can also be done. The evaluation should also be done when the bladder is full and there is insistence urge to urinate. Asked to cough while being checked in the lithotomy position or standing. Leakage of urine can often be seen. Information that can be obtained include the first moment there is a desire to urinate, presence or absence of uncontrollable bladder contractions, and bladder capacity.

3. Laboratory

Electrolytes, urea, creatinine, glucose, and serum calcium assessed to determine kidney function and the conditions that cause polyuria.

4. Note urination (voiding record)

Note voiding was conducted to determine the pattern of urination. This record is used to record the time and the amount of urine when experiencing urinary incontinence and urinary incontinence, and symptoms associated with urinary incontinence. Recording the pattern of urination is done for 1-3 days. The records can be used to monitor therapeutic response and can also be used as a therapeutic intervention as it can sensitize patients the factors that trigger urinary incontinence.

Nursing Interventions for Conjunctivitis : Disturbed Sensory Perception (Visual)

Nursing Care Plan for Conjunctivitis - Nursing Diagnosis : Disturbed Sensory Perception (Visual)


Conjunctivitis is an inflammation of the conjunctiva by viruses, bacteria, chlamydia, allergies, trauma (sunburn) (Barbara C. Long, 1996).

Conjunctivitis is inflammation of the conjunctiva and is characterized by swelling and exudates, eyes appear red so often called red-eye diseases (Brunner and suddarth, 2001).

  • Can be infectious (bacterial, chlamydia, viruses, fungi, parasites).
  • Immunological (allergies).
  • Irritative (chemical, electrical temperature, radiation, for example due to ultraviolet light).

Clinical Manifestations:
Signs and symptoms of conjunctivitis, could include:
  • Hyperemia (redness).
  • Liquid.
  • Edema.
  • Spending tears.
  • Itching on the cornea.
  • Burning / taste scratched.
  • Feels like a foreign object.

Nursing Diagnosis : Disturbed Sensory Perception (Visual) related to damage to the cornea

The expected goals:
Improve visual acuity within the limits of individual situations.

Intervention :
1. Determine acuity, note whether one or both eyes are involved.
Rasionali: individual needs and choice of interventions varied causes vision loss occurs slowly and progressively, if bilateral, each eye may progress at different rates, however, usually only one eye fixed per procedure.

2. Orient the patient on the environment, staff, other people in the area.
Rasionali: Provides increased comfort and familiarity, lowers anxiety and disorientation postoperatively (Marilynn E. Doenges, 2000).

Decreased Cardiac Output and Ineffective Cerebral Tissue Perfusion related to Syncope

 |  in Syncope at  10:03 AM
Nursing Care Plan for Syncope

Definition of Syncope

Syncope is a body mechanism to anticipate changes in the blood supply to the brain and usually occurs suddenly and briefly or loss of consciousness and postural body strength and the ability to stand, because of the reduction of blood flow to the brain. Fainting, "blacking out", or syncope can also be interpreted as a temporary loss of consciousness followed by the return of full alertness.

Syncope is a final establishment of the body in maintaining a lack of substances important for supply to the brain such as oxygen and other substances (glucose) from the damage that could be permanent.

Causes of Syncope

Factors that can trigger syncope is divided into two, namely: psychogenic factors (fear, tension, emotional stress, severe pain that occurs suddenly and unexpectedly and fear the sight of blood or medical equipment such as syringes) and non-psychogenic factors (upright sitting position, hunger, poor physical condition, and the environment is hot, humid and dense).

The most frequent cause of syncope can be divided into several sections such as:

1. Cardiac (Heart) and blood vessels
  • Heart Blockages: Disturbances in the heart can be caused by a blockage (obstruction) in the heart of this blockage can be caused by heart valve disorders, tumors and enlargement of the heart muscle and heart diseases.
  • Heart electricity: Electrical disorders of the heart, causing arrhythmia and cardiac pulsation frequency so that the volume of blood pumped to the body and to the brain will also be reduced.
  • Vertebrobasilar system: The narrowing of the blood vessels due to age, smoking, high blood pressure, high cholesterol, and diabetes. Vertebrobasilar system is risky for the narrowing, and if there is a temporary interruption in blood flow to the midbrain and reticular activating system, fainting or syncope may occur.

2. Innervation
  • Vasovagal syncope: In the human body there are reflexes in the nervous system that are not aware, this nerve reflex can cause a sudden drop in blood pressure. Vasovagal syncope as a result of the action of the vagus nerve which then sends signals to the heart and then slow the heart rate so someone fainting. Vasovagal syncope is usually triggered by fear, pain, injury, fatigue and prolonged standing. Other situations generally cause the heart rate to slow down and cause fainting while as straining, coughing, sneezing (Ocupational syncope) that can cause vagal response.
  • Carotid Sinus: Carotid Sinus is a part of the blood vessels of the neck are very sensitive to physical changes and strain the blood vessels in the area. Because it is too sensitive, then this will result in impulse transmission in the central nervous system that stimulates nerves that make losing consciousness.

3. Influence of body position
  • Orthostatic Hypotension.
  • Postural Hypotension: Blood vessels need to maintain their strength so that the body can withstand the effects of gravity with changes in position. When the body position change from lying to standing, autonomic nervous system increases the strength of the walls of blood vessels, making them shrink, and at the same time increasing the heart rate so that blood can be pumped went up to the brain that cause the blood pressure is relatively low at the moment stand. This is common in the elderly and pregnant women. Typically, fainting happens when a person stands with fast and there was not enough time for the body to compensate. This makes the heart beat faster, and occurs vasoconstriction of blood vessels to maintain the body's blood pressure and blood flow to the brain.

4. Lack of body components
  • Hypoglycemia: Decreased blood sugar suddenly causes a decrease in glucose available to brain function. This can be seen in diabetics who tend to overdose of insulin. If people miss a dose, the dose may be tempted to take extra insulin to make up the missed dose. In such cases, blood sugar tends to suddenly fall, and get people into insulin shock.
  • Electrolyte imbalance: This is due to changes in the concentration of fluid in the body and also directly affects blood pressure in the body.
  • Anemia: Anemia is a condition of a lack of red blood cells (erythrocytes), more specifically, is a hemoglobin (Hb). This causes a lack of oxygen reaching the brain that causes fainting, because hemoglobin is to transport oxygen to the cells in this case the cells in the brain.

5. Other causes
  • Pregnancy: It is caused by the pressure of the inferior vena cava (the large vein that returns blood to the heart) by the enlarged uterus and by orthostatic hypotension.
  • Medications: Other medications may also cause potentially of fainting or syncope including those for high blood pressure that can dilate blood vessels, antidepressants which can affect the heart's electrical activity, and that affects the mental state such as pain medications, alcohol, and cocaine.

Clinical Manifestations of Syncope

Signs symptoms of syncope can be seen in three phases which pre-syncope, syncope and post syncope.

1. Pre syncope:
Patients may feel nauseous, feeling uncomfortable, clammy and weak. There may be a feeling of dizziness or vertigo (the room spinning), hyperpnea (increased depth of breath), vision may be blurred, and there may dampen hearing and tingling sensations in the body. Pre-syncope or near-fainting, the same symptoms will occur, but at this stage the blood pressure and pulse down and the patient did not really lose consciousness.

2. Syncope:
Syncope is characterized by loss of consciousness of patients with clinical symptoms such as:
Short breathing, shallow and irregular.
Bradycardia and hypotension continues.
Palpable pulse weak and convulsive movement in arm muscles, legs and face. In this phase the patient vulnerable to airway obstruction due to the occurrence of muscle relaxation due to loss of consciousness.

3. Post syncope:
The last phase is the post syncope is a recovery period where patients return to consciousness. In the early phases of post-syncope patients may experience disorientation, nausea, and sweating. On clinical examination obtained palpable pulse began to rise and stronger and the blood pressure starts to rise.
After the episode of syncope, the patient should return to normal mental functioning, even though there may be signs and other symptoms depending on the underlying cause of syncope. For example, if the patient is in the midst of a heart attack, he may complain of chest pain or chest pressure.

Nursing Diagnosis and Interventions for Syncope

Nursing Diagnosis : Decreased cardiac output related to the disruption of blood flow to the heart muscle.

Goal: inadequate blood flow to the heart.

Expected outcomes: strong pulse palpation, normal blood pressure.

1. Check the ABC and if necessary freed airway and cardiac massage
Rational: Addressing critical condition early may improve the prognosis of clients.

2. Monitor the pulse rate, respiratory rate, BP regularly.
Rational: Vital signs as the reference condition the patient's circulation.

3. Check the state of the client's heart with ECG examination.
Rational: ECG examination provides an overview heart condition and help determine further treatment alternatives.

4. Assess changes in skin color towards cyanosis and pallor.
Rational: Pale showed a decrease in peripheral perfusion to inadequate cardiac output. Cyanosis occurs as a result of obstruction of blood flow to the ventricles.

5. Monitor intake and output every 24 hours.
Rationale: The kidneys respond to lower cardiac output with production hold fluid and sodium.

6. Limit activities adequately.
Rationale: Adequate rest is needed to improve the efficiency of cardiac contraction and lower oxygen consumption and excessive work.

Nursing Diagnosis : Ineffective Cerebral Tissue Perfusion related to a decrease in the flow of oxygen to the cerebral.

Expected outcomes: Vital signs are stable, patient-oriented with good communication.

1. Monitor vital signs
Rational: Vital Signs is one indicator of the general state and the patient's circulation.

2. Position the patient in the shock position foot raised 45 degrees.
Rationale: Helps improve venous return to the heart and subsequently increased cerebral blood flow.

3. Monitor the level of consciousness.
Rationale: The level of a person's consciousness is also influenced by the perfusion of oxygen to the brain.

4. Provide adequate oxygen therapy.
Rationale: to prevent more severe brain hypoxia.

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