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Nursing Intervention and Rational - Ineffective Airway Clearance for Nursing Care Plan Bronchial Pneumonia

Nursing Diagnosis: Ineffective Airway Clearance

Related to:
  • Tracheobronchial inflammation, edema formation, increased sputum production
  • Pleuritic pain
  • Decreased energy, weakness

Possible evidenced by:
  • Changes in the frequency of respiratory depth
  • Abnormal breath sounds, accessory muscle use
  • Dyspnea, cyanosis
  • Cough effective / ineffective with / without sputum production

Expected Results:
  • Behavior to achieve cleanliness airway
  • Showed a patent airway with breath sounds clean, no dyspnea or cyanosis

Nursing Intervention:

Independent
  • Assess the frequency / depth of breathing and chest movement
  • Pulmonary auscultation, note the areas of decreased / no air flow and additional breath sounds (cracles, wheezing)
  • Help the patient to cough effectively and breath in
  • Suction as indicated
  • Give fluids at least 2500 ml / day

Collaboration
  • Help monitor the effects of nebulizer treatment and other physiotherapy
  • Give medications as indicated: mukolitik, expectorant, bronchodilator, analgesic
  • Give extra fluids
  • Watch the ray series 'X' chest, GDA, the pulse oximetry
  • Help bronchoscopy / thoracic synthesis when indicated