Nursing Diagnosis : Ineffective Airway Clearance - NCP Bronchitis

Nursing Care Plan for Bronchitis 


Nursing Diagnosis : Ineffective Airway Clearance

Definition : Inability to clear secretions or obstruction of the respiratory tract to maintain the cleanliness of the airway.

Defining characteristics :

• Dyspnea , decreased breath sounds.
• Orthopnoea.
• Cyanosis.
• Abnormalities of breath sounds (rales, wheezing)
• Difficulty speaking.
• Cough, ineffective or non-existent.
• Eyes widened.
• Sputum production.
• Restless.
• Changes in the frequency and rhythm of the breath.

Related factors :

• Environment : smoking, inhaling cigarette smoke, secondhand smoke, infection.
• Physiological : neuromuscular dysfunction, hyperplasia of the bronchial wall, airway allergies, asthma.
• Airway obstruction : airway spasm, retained secretions, much mucus, the presence of artificial airway, bronchial secretions, presence of exudate in the alveoli, the presence of foreign bodies in the airway.

NOC :

• Respiratory Status: Ventilation
• Respiratory status : Airway patency
• Aspiration Control

Outcomes :

• Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips).
• Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds).
• Being able to identify and avoid factors that can inhibit airway.

NIC :
Airway Suctioning

• Ensure the needs of oral / tracheal suctioning.
• Auscultation of breath sounds before and after suctioning.
• Inform the client and family about suctioning.
• Ask the client a deep breath before suction is done.
• Give O2 by using a nasal, to facilitate nasotracheal suction.
• Use sterile equipment every action.
• Instruct the patient to rest and breath in after catheter removed from nasotracheal.
• Monitor the patient's oxygen status.
• Teach the family how to do suction .
• Stop suction and administer oxygen if the patient showed bradycardia, an increase in O2 saturation, etc..

Airway Management

• Open the airway , use techniques jaw thrust or chin lift if necessary.
• Position the patient to maximize ventilation.
• Identification of patients , the need for installation of an artificial airway.
• Attach mayo if necessary.
• Perform chest physiotherapy if necessary.
• Remove secretions by coughing or suctioning.
• Auscultation of breath sounds, note the presence of additional noise.
• Perform suction on the mayo.
• Give bronchodilators if necessary.
• Give Kassa humidifier moist wet NaCl.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status.