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Ineffective Airway Clearance and Activity Intolerance - NCP for Atelectasis

 |  in Nursing Care Plan at  10:17 AM

Nursing Diagnosis and Interventions for Atelectasis

Atelectasis is lung development is not perfect. Atelectasis is not actually a disease but is related to pulmonary parenchymal disease.

Clinical Manifestations
  • May not experience symptoms.
  • Mild shortness of breath: when is advanced in which up to half a lung inflammatory infiltration.
  • Cough: is due to the irritation of the bronchi, coughing is to throw / pull production inflammation, starting from a dry cough up purulent cough (produces sputum).
  • Chest pain: This is rare, occurs when the infiltration of inflammatory pain up to the pleura, giving rise to pleurisy.
  • Malaise: is found in the form of anorexia, decreased appetite, weight loss, headache, muscle aches, sweating at night time.
  • Tachycardia.
  • Cyanosis.
  • Heat or high temperature: subfebril, febrile (38-40 0C) intermittent.
  • Shock or loss of consciousness.
  • The location of the diaphragm will be elevated, reduced chest movement on the affected side.
  • May limit the heart and mediastinum will shift towards the sick.
  • Dullness or flat on the side that suffered atelectasis.
  • Additional breath sounds (crackles).
  • In broad atelectasis noisy breath weakened or no sound at all.
  • There are differences in the thoracic wall motion, the motion between the ribs and diaphragm. In the normal movement of the chest will tune during inspiration and expiration, but the client atelectasis chest movement on the affected side will be left of the chest movement on the healthy side.

Nursing Diagnosis for Atelectasis  : Ineffective Airway Clearance related to bronchial obstruction by mucus clot or foreign body

Characterized by:
  • Ineffective cough.
  • Secretions can not get out.
  • Additional breath sounds (eg crackles).
  • Increased RR, rapid and shallow breaths.

Goal:
Exhibit a client achieve airway clearance

Outcomes:
  • Clients can implement an effective cough.
  • Secretions can be removed.
  • Showed an increase in air exchange in the lungs.

Intervention:

1. Instruct clients to perform effective cough right:
  • Breath deeply and slowly as possible while sitting if able.
  • Use respiratory diaphragm.
  • Hold breath for 3-5 seconds and then exhale slowly through the mouth.
  • Take a second breath, hold it, and with a strong cough from the chest (use two short coughs really strong).
2. Maintain proper body position with.
3. Assist clients to dispense with the method of physiotherapy airway secretions (klepping, vibrating, or postural drainage).
4. Breaks Plan period (after coughing, before eating).
5. Guided and motivated clients to implement effective cough.
6. Collaboration with doctors for giving bronchodilators and suction (for spending secretions).
7. Record sputum characteristics (amount, color, odor).
8. Assess whether the client still feels pain.
9. Observation additional sound in the lungs, decreased chest wall expansion.


Nursing Diagnosis for Atelectasis  : Activity Intolerance related to impaired O2 transport system secondary to atelectasis

Characterized by:
  • Malaise.
  • Clients say have a headache / dizziness.
  • Increased RR.
  • Increased pulse rate.
  • Cyanosis.
Goal:
Clients can perform the activity on the bed.

Outcomes:
  • After minimal activity (in bed), the client shows:
  • RR and pulse frequency are within normal limits.
  • Headache / dizziness that is felt to have diminished or disappeared.

Intervention:

1. Encourage clients to be aware and controlled breathing (diaphragmatic breath and breathing lips) during increased activity and time of emotional and physical stress.
  • Breath lips: the client should breathe in through your nose and then exhale slowly through the mouth slightly open.
  • Breath diaphragm: nurse lay hands on the abdomen below the ribs basis and remain in place while the client to breathe air. For inhalation, the client should relax your shoulders, inhale through the nose, stomach and push against the hand of a nurse, hold the breath for 1-2 seconds to keep the alveoli open, then exhale slowly through the mouth.
2. Motivate the client to keep the airway activities several times each hour.
3. Encourage an increase in the daily activities on the client gradually to prevent lung paralysis.
4. Monitor client's response to the activity:
Measure vital signs immediately after the activity (pulse and RR).
Rest client for 3 minutes and then re-measure the vital signs.
Reduce the intensity, frequency, or duration of activity if the breath frequency increases after excessive activity.

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