Nursing Diagnosis Ineffective Airway Clearance
related to:
Goal :
a. Assess respiratory function: breath sounds, speed, rhythm, depth and accessory muscle use.
Rationale: Decreased breath sounds indicate atelectasis, Ronchi indication of accumulation of secretions / inability of clearing the airway so that the accessory muscle use and increased work of breathing.
b. Note the ability to remove secretions or cough effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: Expenditures difficult when thick secretions, sputum, bleeding from the bronchial lung damage or injury that requires evaluation / intervention information.
c. Give the patient or the semi-Fowler position, Help / teach effective coughing and breathing exercises.
Rationale: Increased lung expansion, maximum ventilation opening areas of atelectasis and increased secretions movement to be easily removed.
d. Clean secretions from the mouth and trachea, suction if necessary.
Rationale: To prevent obstruction / aspiration. Suction done when patients are unable to remove secretions.
e. Maintain a fluid intake of at least 2500 ml / day unless contraindicated.
Rationale: Helps thin the secretions so easily removed.
f. Moisten the air / oxygen inspiration.
Rationale: Prevents drying of mucous membranes.
g. Give medications: bronchodilators, corticosteroids as indicated.
Rational: Lowering the viscosity of secretions, circle trakeabronkial lumen size, handy in case of hypoxemia in a wide cavity.
h. Help incubation emergency if necessary.
Rational: It takes the rare cases bronkogenik. with laryngeal edema or acute pulmonary hemorrhage.
related to:
- thick secretions or blood secretions,
- weakness,
- bad cough effort,
- edema, tracheal / pharyngeal.
Goal :
- Maintaining a patient's airway.
- Removing secretions without help.
- Demonstrate behaviors to improve airway clearance.
- Participate in treatment programs according to the conditions. Identify potential complications and appropriate action.
a. Assess respiratory function: breath sounds, speed, rhythm, depth and accessory muscle use.
Rationale: Decreased breath sounds indicate atelectasis, Ronchi indication of accumulation of secretions / inability of clearing the airway so that the accessory muscle use and increased work of breathing.
b. Note the ability to remove secretions or cough effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: Expenditures difficult when thick secretions, sputum, bleeding from the bronchial lung damage or injury that requires evaluation / intervention information.
c. Give the patient or the semi-Fowler position, Help / teach effective coughing and breathing exercises.
Rationale: Increased lung expansion, maximum ventilation opening areas of atelectasis and increased secretions movement to be easily removed.
d. Clean secretions from the mouth and trachea, suction if necessary.
Rationale: To prevent obstruction / aspiration. Suction done when patients are unable to remove secretions.
e. Maintain a fluid intake of at least 2500 ml / day unless contraindicated.
Rationale: Helps thin the secretions so easily removed.
f. Moisten the air / oxygen inspiration.
Rationale: Prevents drying of mucous membranes.
g. Give medications: bronchodilators, corticosteroids as indicated.
Rational: Lowering the viscosity of secretions, circle trakeabronkial lumen size, handy in case of hypoxemia in a wide cavity.
h. Help incubation emergency if necessary.
Rational: It takes the rare cases bronkogenik. with laryngeal edema or acute pulmonary hemorrhage.
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