Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Interventions for Bronchiectasis

Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Bronchiectasis may result from a number of infective and acquired causes, including pneumonia, tuberculosis, immune system problems, and cystic fibrosis.

The cause in 10-50% of those without cystic fibrosis is unknown.

Symptoms typically include a chronic cough productive of mucus. Other symptoms include shortness of breath, coughing up blood, and chest pain. Wheezing and nail clubbing may also occur. Those with the disease often get frequent lung infections.

The mechanism of disease is breakdown of the airways due to an excessive inflammatory response. Involved bronchi become enlarged and thus less able to clear secretions. These secretions increase the amount of bacteria in the lungs, result in airway blockage and further breakdown of the airways.

Nursing Diagnosis and Interventions for Bronchiectasis

Ineffective Airway Clearance related to the production of mucus and a decreased ability to cough effectively.

Goal: The airway re-effective, eliminating the quantity of sputum viscosity to improve pulmonary ventilation and gas exchange.

Expected outcomes: Clients can:
  • demonstrate effective cough,
  • mention ways to lower the viscosity of secretions,
  • no additional breath sounds, and
  • normal breathing (16-20 x / min) without the use of accessory muscles of breath.

Interventions :
  • Assess color, viscosity, and the amount of sputum.
  • Adjust the position of the semi-Fowler.
  • Teach how to cough effectively.
  • Assist clients in the breathing exercises.
  • Maintain fluid intake at least 2500 ml / day unless otherwise indicated.
  • Perform chest physiotherapy with postural drainage techniques, percussion, and chest vibrations.
  • Collaboration of bronchodilators: Nebulizer (via inhalation) Collaboration of mucolytic agent and expectorant.
  • Collaboration of corticosteroids.

Rationale :
  • Sputum characteristics can indicate the severity of the obstruction.
  • Improve chest expansion.
  • Cough controlled and effective spending can facilitate the embedding secret airway.
  • Maximum ventilation opening the airway lumen and increase the movement of secretions in the airway to be issued.
  • Adequate hydration help thin secretions and make effective airway clearance. In addition, to increase fluid intake is the tendency of clients to breathe through the mouth which increases water loss. Inhalation of vaporized water is also helpful because this steam can humidify bronchial branching.
  • Postural drainage with percussion and vibration using the help of gravity to help raise secretions that can be removed or sucked easily. Clients are instructed to breathe and cough effectively to help remove secretions. Postural drainage is usually done when the client wakes up, to get rid of secretions that have accumulated throughout the night, and before the rest, to improve the quality and quantity of sleep.
  • Administration of bronchodilators via inhalation will go directly to the bronchial area, which experienced a spasm so more quickly dilated.
  • Mucolytic agents decrease the viscosity and pulmonary adhesions secret for easy cleaning.
  • Expectorant agent will facilitate secret escape from adhesions airway.
  • Corticosteroids are useful in the broad engagement with hypoxemia and decrease the inflammatory reaction due to mucosal edema and bronchus wall.

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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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