Ineffective Airway Clearance - Empyema Nursing Care Plan
Ineffective Airway Clearance - Empyema Nursing Care Plan
Objectives:
Characteristics:
Expected Results :
Nursing Intervention and Rational for Ineffective Airway Clearance - Empyema Nursing Care Plan
1. Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, tachipneu a degree found the process of acute infection.
2. Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)
3. Note the presence or degree of dyspnoea, restlessness, anxiety, and respiratory distress
R /: respiratory dysfunction is a chronic stage of the process that can cause infections or allergic reactions.
4. Maintain a pollution-free environment
R /: type triggers an allergic reaction which can trigger respiratory acute episodes
5. Assess the patient to a comfortable position, such as elevation of the head of the bed.
R /: Elevation headboard facilitate respiratory function by using gravity.
6. Abdominal breathing exercises or lips.
R /: Giving patients a variety of ways to cope with and control of dyspnoea and reduce air entrapment.
7. Observation of the characteristic cough
R /: A cough can be persistent but not particularly effective if the patient is elderly, acute pain, or weakness.
8. Increase fluid intake to 3000 ml per day according to tolerance of the heart.
R /: Hydration helps lower the viscosity of secretions, makes expenditures
9. Giving medication as indicated
R /: relaxes smooth muscle and reduce local congestion, reduce airway spasm, wheezing, and mucous production.
Nursing Diagnosis
related to :
- bronchus spsame,
- increased production of secretions,
- weakness
Objectives:
- Effective Airway Clearance
Characteristics:
- Verbally expressed difficulty in breathing
- Use of auxiliary respiratory muscles
- Wheezing, Ronchi, cracles
- Cough (persistent) with / without sputum production
Expected Results :
- The sound of breathing clean
- Effective Cough
- Wheezing (-), Ronchii (-) Cracles (-)
Nursing Intervention and Rational for Ineffective Airway Clearance - Empyema Nursing Care Plan
1. Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, tachipneu a degree found the process of acute infection.
2. Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)
3. Note the presence or degree of dyspnoea, restlessness, anxiety, and respiratory distress
R /: respiratory dysfunction is a chronic stage of the process that can cause infections or allergic reactions.
4. Maintain a pollution-free environment
R /: type triggers an allergic reaction which can trigger respiratory acute episodes
5. Assess the patient to a comfortable position, such as elevation of the head of the bed.
R /: Elevation headboard facilitate respiratory function by using gravity.
6. Abdominal breathing exercises or lips.
R /: Giving patients a variety of ways to cope with and control of dyspnoea and reduce air entrapment.
7. Observation of the characteristic cough
R /: A cough can be persistent but not particularly effective if the patient is elderly, acute pain, or weakness.
8. Increase fluid intake to 3000 ml per day according to tolerance of the heart.
R /: Hydration helps lower the viscosity of secretions, makes expenditures
9. Giving medication as indicated
R /: relaxes smooth muscle and reduce local congestion, reduce airway spasm, wheezing, and mucous production.
