Ineffective Airway Clearance related to Pneumonia
Nursing Care Plan for Pneumonia
Pneumonia is one of the diseases of respiratory tract infection is the most established and often a cause of death in almost all the world.
Most are caused by microorganisms, but also by other ingredients, so it is known:
The clinical picture is usually preceded by an acute infection of the upper respiratory tract for several days, followed by fever, body temperature sometimes exceeding 40 degrees C, sore throat, muscle and joint pain. Also accompanied by cough, sputum mucoid or purulent, sometimes bloody.
Nursing Diagnosis and Interventions
Ineffective airway clearance related to tracheobronchial inflammation, edema formation, increased sputum production.
Goal:
Intervention:
1. Auscultation of breath sounds, note the breath sounds. For example: wheezing, crackles.
Rationale: Airway clearance ineffective can be manifested in the presence of breath sounds adventisius.
2. Assess / monitor respiratory rate, record the ratio of inspiration / expiration.
Rational: Tachypnea usually exist in some degree and can be found at the reception or during stress / presence of acute infectious process. Breathing can be slowed, and the frequency of expiration elongated than inspiration.
3. Provide a comfortable position for the patient, such as semi-Fowler position.
Rationale: The position of the semi-Fowler will facilitate the patient to breathe
4. Encourage / aids abdominal breathing exercises or lips.
Rationale: Giving the patient a few ways to cope with and control dipsnea and lower air entrapment.
5. Observe the characteristic cough, auxiliary measures to improve the effectiveness of efforts to cough.
Rationale: A cough may persist, but ineffective. The most effective cough in high sitting position or head down after chest percussion.
6. Provide warm water as tolerated heart.
Rational: Hydration lowers the viscosity of secretions and facilitate spending.
Pneumonia is one of the diseases of respiratory tract infection is the most established and often a cause of death in almost all the world.
Most are caused by microorganisms, but also by other ingredients, so it is known:
- Lipid pneumonia: therefore aspiration of mineral oil.
- Chemical pneumonitis: inhalation of organic materials or chemical vapors such as beryllium.
- Extrinsic allergic alveolitis: inhalation of material dust containing allergens, such as dust.
- Drug Reaction pneumonitis.
- Pneumonia due to X-ray radiation.
- Pneumonia is not clear: desquamative interstitial pneumonia, eosinophilic pneumonia.
- Microorganisms.
Nursing Diagnosis and Interventions
Ineffective airway clearance related to tracheobronchial inflammation, edema formation, increased sputum production.
Goal:
- Airway effectively with breath sounds clean and clear.
- Patients can perform effective cough to remove secretions
- Maintain a patent airway with breath sounds clean / clear.
- Show behavior to improve airway clearance.
- Example: effective cough and remove secretions.
Intervention:
1. Auscultation of breath sounds, note the breath sounds. For example: wheezing, crackles.
Rationale: Airway clearance ineffective can be manifested in the presence of breath sounds adventisius.
2. Assess / monitor respiratory rate, record the ratio of inspiration / expiration.
Rational: Tachypnea usually exist in some degree and can be found at the reception or during stress / presence of acute infectious process. Breathing can be slowed, and the frequency of expiration elongated than inspiration.
3. Provide a comfortable position for the patient, such as semi-Fowler position.
Rationale: The position of the semi-Fowler will facilitate the patient to breathe
4. Encourage / aids abdominal breathing exercises or lips.
Rationale: Giving the patient a few ways to cope with and control dipsnea and lower air entrapment.
5. Observe the characteristic cough, auxiliary measures to improve the effectiveness of efforts to cough.
Rationale: A cough may persist, but ineffective. The most effective cough in high sitting position or head down after chest percussion.
6. Provide warm water as tolerated heart.
Rational: Hydration lowers the viscosity of secretions and facilitate spending.
