List of Nursing Diagnosis

Nursing Diagnosis and Interventions for Hypoglycemia

Ineffective Airway Clearance related to airway obstruction / increase in tracheobronchial secretions.

Defining characteristics :

• Dyspnoea.
• Orthopnea.
• Cyanosis.
• Crackles / crepitations.
• Difficulty speaking.
• Cough is ineffective or non-existent.
• Eyes widened.
• Increased sputum production.
• Restless.
• Changes in the frequency and rhythm of breathing.

NOC :

Goal : Effective airway

Outcomes :

• Respiration Status : Patency Road Breath :
• Breath sounds clean.
• No cyanosis.
• No shortness of breath / dyspnea.
• The rhythm of breathing and respiratory rate within normal range.
• Do not feel suffocated.
• No cyanosis.
• No agitated.
• Sputum is reduced.

Respiratory Status : Ventilation

• Demonstrate effective cough.
• Breath sounds were clean.
• No cyanosis.
• No dyspnoea (able to breathe more easily).
• No pursed lips.

NIC / Intervention

Airway Suctioning :

1. Ensure suctioning needs .
2. Auscultation of breath sounds before and after suctioning.
3. Inform the client and family about suctioning.
4. Asking clients a deep breath before suctioning.
5. Give oxygen by nasal cannula to facilitate nasotracheal suctioning.
6. Use sterile equipment every action.
7. Encourage clients a deep breath and rest after the catheter is removed from the nasotracheal.
8. Monitor the status of the client oxygen.
9. Stop suction when the client showed bradycardia.

Airway Management :

1. Open the airway, use techniques chin lift or jaw thrust if necessary.
2. Position the client to maximize ventilation.
3. Identification of the need for client installation artificial airway.
4. Attach the OPA if necessary.
5. Perform chest physiotherapy if necessary.
6. Remove secretions by coughing or suctioning.
7. Auscultation of breath sounds, note the presence of additional noise.
8. Collaboration of bronchodilators if necessary.
9. Monitor respiration and oxygen status.

Cough Enhancement :

1. Monitor lung function, vital capacity, and maximal inspiration.
2. Encourage the patient to do deep breathing, coughing arrested last 2 seconds 2-3 times.
3. Encourage clients a deep breath several times, released slowly and cough at the end of expiration.

Oxygen Therapy :

1. Clean the secret in the mouth, nose and trachea / throat.
2. Maintain airway patency.
3. Explain to the client / family about the importance of giving oxygen.
4. Give oxygen as needed.
5. Select the appropriate equipment needs : nasal cannula 1-3 l / min, head box 5-10 l / min , etc..
6. Monitor O2 flow.
7. Monitor O2 hose.
8. Periodically check the O2 hose, humidifier, O2 flow.
9. Observation O2 deficiency signs : restlessness, cyanosis, etc..
10. Monitor signs of poisoning O2.
11. Maintain O2 during transport.
12. Instruct client / family to observe the O2 supply, water humidifier, if the report finished guard.

Adjusting the position

• Adjust the position of the patient semi-Fowler , head extension .
• Tilt the head when vomiting .

Cchest Physiotherapy

1. Determine the presence of contraindications chest physiotherapy .
2. Determine lung segments that require chest physiotherapy .
3. Position the client with lung segments which require drainage placed higher .
4. Use a pillow to help position the head .
5. Combine techniques posturnal percussion and drainage .
6. Combine fibrasi and posturnal drainage techniques .
7. Manage inhalation therapy .
8. Manage administration of a bronchodilator , mucolytics .
9. Monitor and type of sputum .
10. Encourage coughing before and after posturnal drainage .

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.

Nursing Interventions for Tuberculosis

Nursing diagnosis: ineffective airway clearance related to hypersecretion

characterized by a thick secretions or blood.

Objective:

• ffective airway clearance.

Expected outcomes:

• Finding a comfortable position that allows increased air exchange.
• Demonstrate effective cough.
• Stated strategy to reduce the viscosity of secretions.

Plan of Action:

1. Explain to the client about the use of effective coughing and why there is a buildup of secretions in the respiratory tract.
Rationale: Knowledge that will hopefully help develop adherence to the treatment plan.

2. Teach the client about the proper method of controlling cough.
Rationale: Uncontrollable cough is exhausting and ineffective, causing frustration.

3. Breath deeply and slowly when sitting as upright as possible.
Rationale: Allows greater lung expansion.

4. Perform respiratory diaphragm.
Rationale: Respiratory diaphragm lower frequency of breath, and increased alveolar ventilacion.

5. Hold your breath for 3-5 seconds and then slowly remove as much as possible through the mouth. Do a second breath, hold it and batukan of the chest by two short and strong cough.
Rationale: Increasing the volume of air in the lung secretions facilitate spending.

6. Auscultation of the lungs before and after coughing clients.
Rationale: This helps evaluate the effectiveness.

7. Teach client action to reduce secretion: adequate hydration, increase fluid intake 1000 till 1500 cc / day if not contraindicated.
Rational: viscous secretion is difficult to dissolve and can cause blockage of mucus that leads to atelectasis.

8. Perform chest physio claping / vibrating.
Rationale: With a gravity discharge will come out to big and ease spending alveol secretions.

9. Collaboration with other health team physicians, radiology.

• Giving expectoran.
• Giving antibiotics.
• Consul thorax X-ray.

Rational: Expektoran to facilitate mucus and evaluate client improvement of lung development.