Friday, August 16, 2013

Ineffective Airway Clearance related to Bronchopneumonia


Nursing Care Plan for Bronchopneumonia

Ineffective Airway Clearance : Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Bronchopneumonia is a type of pneumonia. Pneumonia is inflammation of the lungs, caused by infection from viruses, bacteria, or fungi. The infection causes inflammation in the alveoli (also known as air sacs) in the lungs, causing the alveoli to become filled with pus or fluid.

Both forms of pneumonia are often caused by coming into contact with viruses and bacteria in your day-to-day routine. Most cases of bacterial pneumonia are caused by the bacterium Streptococcus pneumonia; however, it is not uncommon for pneumonia to be caused by more than one type of bacteria. Other possible culprits include:
  • Staphylococcus aureus
  • Haemophilus influenzae
  • Klebsiella pneumoniae
Most cases of viral pneumonia are caused by the same viruses that cause cold and flu.


Nursing Diagnosis for Bronchopneumonia

Ineffective Airway clearance related to increased sputum production

Subjective Data
  • Patients complain of fuss
  • Patients complain of shortness of breath
  • Patients do not want to eat
  • Parents expressed not understand about his illness

Objective Data
  • Breathing fast and shallow
  • Nostril breathing
  • Ronchi and cyanosis
  • Coughing purulent sputum
  • The use of auxiliary respiratory muscles
  • Breath sounds bronchovesikuler
  • vomiting vomiting
  • Malaise
  • Decreased appetite and weight loss
  • Increased respiration

Goals:

Clean and effective airway after the treatment, the criteria:
  • No dypsnoe, cyanosis, Ronchi
  • BGA mormal

Intervention:
  1. Assess the respiratory rate, record the ratio of inspiration / expiration.
  2. Perform auscultation of breath sounds, note the presence of breath sounds. For example: wheezing, crackles.
  3. Provide semi-Fowler position.
  4. Provide a warm drink a little bit but it often.
  5. Implement the discretionary actions: bronchodilator, mucolytics, to liquefy phlegm so easily removed.

Rational:
  1. Tachypnea is usually present in some degree and can be found at the reception or during stress / presence of acute infectious process. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
  2. Airway clearance ineffective may be manifested in the presence of breath sounds adventisius.
  3. Semi-Fowler position will make it easier for patients to breathe.
  4. Hydration decrease the viscosity of secretions and facilitate expenditure.
  5. Provision of medicines pengerncer sputum airway facilitate the evacuation process.

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