Nursing Diagnosis 1. :
Ineffective airway clearance related to thick secretions, increased mucus production, bronchospasm.
1. Goal
- Airway becomes effective.
2. Outcomes
- Determining a comfortable position so as to facilitate an increase in gas exchange.
- Can demonstrate an effective cough.
- May declare a strategy to decrease the viscosity of secretions.
- No additional breath sounds.
3. Interventions
- Assess color, consistency and amount of sputum.
- Instruct clients on appropriate methods in controlling cough.
- Teach the client to reduce the viscosity of secretions.
- Auscultation of the lungs before and after the action.
- Perform chest physiotherapy techniques with postural drainage, chest percussion and fibrasi.
- Push and or provide oral care.
4. Rational
- Sputrum characteristics can indicate the severity of the obstruction.
- Uncontrolled coughing ineffective and exhausting and frustrating.
- Thick secretions difficult untuyk issued and can cause blockage of mucus that can cause atelectasis.
- Additional noise reduced after action indicates success.
- Fisioterpi chest is a strategy to remove secretions.
- Good oral hygiene improve the taste of healthy and prevent bad breath.
Nursing Diagnosis 2. :
Ineffective breathing pattern related to chest wall distention, and fatigue due to increased work of breathing.
1. Goal
- Clients will demonstrate effective breathing pattern.
2. Outcomes
- Effective breathing frequency and improved gas exchange in the lungs.
- Stating the causes and ways to overcome adaptive to these factors.
3. Interventions
- Monitor the frequency, rhythm and depth of breathing.
- Position the client's chest semi-Fowler position.
- Distract people from thinking about the state of anxiety and teach how to breathe effectively.
- Minimize gastric distention.
- Assess breathing during sleep.
- Reassure the client and give support when dyspnea.
4. Rational
- Tachypnea, irregular rhythm and breathing shallow demonstrate ineffective breathing pattern.
- Semi-Fowler position lowers the diaphragm so as to give the development of the pulmonary organs.
- Anxiety can lead to ineffective breathing pattern.
- Gastric distension may inhibit contraction diaphragm.
- Presence of sleep apnea show ineffective breathing pattern.
- Sense of hesitation on the client can inhibit therapeutic communication.
Nursing Diagnosis 3. :
Impaired gas exchange related to CO2 retention, increased secretion, increased respiration, and disease processes.
1. Goal
- The client will maintain adequate gas exchange and oxygenation.
2. Outcomes
- Frequency of breathing 16-20 times / min
- Pulse frequency 60-120 times / min
- Normal skin color, no dyspnea and GDA within normal limits.
3. Interventions
- Monitoring of respiratory status every 4 hours, the results of GDA, income and output.
- Place client in semi-Fowler position.
- Give intravenous therapy as directed.
- Give oxygen via nasal cannula 4 l / meniit, then adapt the results of PaO 2.
- Give the medication that has been prescribed and observe if there are signs of toxicity.
4. Rational
- To identify the indications towards progress or deviations from the client.
- Upright position allowing better lung expansion.
- To enable rapid rehydration and can assess the situation for vascular administration of emergency drugs.
- Giving oxygen to reduce the burden of respiratory muscles.
- Treatment to restore bronchial conditions as the previous conditions.
- For ease breathing and prevent atelectasis.
