Ineffective Airway Clearance related to Asphyxia Neonatorum

Nursing Diagnosis :

Nursing Interventions : Ineffective airway clearance related to obstruction of mucus.

Nursing Outcomes:

Repiration status: Ventilation
Indicators:

• Free of abnormal breath sounds.
• No shortness of breath.
• Respiration rate is within the normal range.
• Regular respiratory rhythm.
• No retraction of the chest.

Assessment scale:

1. Extremely compromised.
2. Substantially compromised.
3. Moderately compromised.
4. Mildly compromised.
5. Not compromised.

Nursing Interventions

Airway management

• Open the airway.
• Position the patient to maximize ventilation.
• Identification of patients need artificial airway appliance installation.
• Remove secretions by suction.
• Auscultation of breath sounds, note the presence of additional noise.
• Set intake to optimize fluid balance.
• Monitor respiration and O2 status every 6 hours.

Vital sign monitoring

• Monitor blood pressure, pulse, temperature, and respiration.
• Monitor quantities and heart rhythm.
• Monitors heart sounds.
• Monitor lung sounds.
• Monitor abnormal breathing patterns.
• Monitor temperature, color, and moisture.
• Monitor peripheral cyanosis.
• Identify the causes of changes in vital signs.

Oxygen therapy

• Setting up the oxygen equipment and a humidifier.
• Provide supplemental oxygen by order.
• Monitor the liter flow of oxygen.
• Monitoring canule position.
• Monitor signs of oxygen toxicity.

Rationale:

• Patency of the airway is the main requirement to obtain adequate ventilation.
• Helping lungs to meet the body's need for oxygen.
• Assessing changes in status, to determine actions to improve / maintain the status respiration.

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Ineffective Airway Clearance and Ineffective Breathing Pattern NCP for Epilepsy

Definition of Epilepsy

Epilepsy is a chronic neurological disease that causes seizures periodically. The disease is caused by the normal activity of brain cells. Symptoms of seizures that appears may vary. Some people with epilepsy when seizures have an empty view. Mild seizures require treatment, because it can be dangerous in the event when doing activities like driving or swimming.

Treatments such as medical treatment and sometimes surgery is usually successful in eliminating the symptoms or reduce the frequency and intensity of seizures. In some children with epilepsy, they can overcome this condition with age.

Recently, the researchers found, epilepsy affects neurological function disrupt social functioning in the brain, the same properties are also seen in people with autism. These characteristics include impairments in social interaction and communication.

Symptoms of Epilepsy

Because epilepsy is not normally caused by the activity of brain cells, seizures can have an impact on your brain coordination process. Convulsions can result in:

• Temporary confusion.
• Uncontrolled jerking movements of the hands and feet.
• Lost consciousness completely.

Differences symptoms occur depending on the type of seizures. In many cases, people with epilepsy will tend to have this type of seizure is the same every time, so it will be the same symptoms that occur from incident to incident.

Doctors classify partial seizures or generalized, based on how abnormal brain activity begins. In some cases, seizures can be initiated by partial and later became general.

Partial Seizures

When seizures arise as a result of abnormal brain activity on the part of the brain, scientists call it partial seizures. Seizures of this type consists of two categories.

• Simple partial seizures. These seizures do not result in loss of consciousness. These seizures may be changing emotions or changing way of looking at, smell, feel, taste, or hear. These seizures can also produce buffeting parts of the body by accident, such as the hands or feet, and sensory symptoms such as tingling spontaneously, vertigo and blinking against the light.
• Complex partial seizures (complex partial seizures). These seizures resulted in the change of consciousness, it is because you lose vigilance for some time.

General Seizures

Seizures involving all parts of the brain called the general convulsions. Four types of general convulsions are:

• Absence seizures (also called petit mal). This seizure is characterized by the movement of the body has a smooth and striking, and can cause loss of consciousness briefly.
• Myoclonic seizures. These seizures usually cause a jerk or twitch suddenly in the hands and feet.
• Atonic seizures. Also known as drop attacks, these seizures cause loss of harmony with the muscles and the sudden collapse and fall.
• Tonic-clonic seizures (also called grand mal). Convulsions that have most frequently occurring intensity. Having characteristics with loss of consciousness, stiff and trembling, and loss of bladder control.

Nursing Care Plan for Epilepsy

Nursing Diagnosis : Ineffective Airway Clearance and Ineffective Breathing Pattern

related to damage nuromuskuler , tracheobronchial obstruction .

Nursing Interventions:

1) Encourage clients to release the use of objects from the mouth preformance, hammer and other tooth samples.
Rationale: lowering the risk of aspiration or the entry of foreign objects into the pharynx.

2). Place the patient in the lateral position, a flat surface, tilt the head during a seizure occurs.
Rationale: improving drainage secret, to prevent the tongue falling, and obstruct the airway.

3). Remove clothing at the neck, chest and abdomen clients.
Rational: to help clients breathe.

4). Insert the tongue into the mouth spatel clients.
Rational: to prevent biting the tongue and help perform suction mucus, and help open the airway.

5). Perform suction as indicated.
Rationale: lowering the risk of aspiration or asphyxia.

6). Collaboration in the provision of supplemental oxygen.
Rational: can decrease cerebral hypoxia, due to reduced oxygen due to vascular spasm during seizures.

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Ineffective Airway Clearance related to Sinusitis

Nursing Diagnosis Ineffective Airway Clearance related to Sinusitis

Sinusitis or sinus infection can cause a great deal of pain. It is the result of an inflammation of the sinus or nasal passages or both. When someone has a sinus infection there are several symptoms that will help him or her to recognize that that is what he or she are suffering from. Sinusitis is often accompanied by a feeling of tenderness or pressure around the nose, eyes, cheeks or forehead. Sometimes it is accompanied by headache pain.

Sinusitis can come on suddenly and then leave after the correct treatment, lasting a few weeks, or it can be a chronic problem that lasts more than eight weeks at a time with at least four occurrences yearly. Surprisingly most cases of sinusitis are chronic in nature.

Sinusitis treatment through medical or home methods can be done to make you feel better. The goals of these treatments are the improvement of drainage of mucus, reduce swelling in the sinuses, relieve pain and pressure, clear up any infection, prevent the formation of scar tissue, and avoid permanent damage to the tissues lining the nose and sinuses.

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness.

Nursing Care Plan for Sinusitis

Ineffective Airway Clearance related to obstruction / secret is thickened.

Purpose: Purpose: return airway is effective, within 10-15 minutes.

Expected outcomes are:

a) The client no longer uses the nostril breathing

b) The absence of additional breath sounds

c) Ronchi (-)

d) Respiration = 16-20 times / minute

e) The absence of chest wall retraction in 10-15 minutes.

No	Nursing Interventions	Rational
1.	Collaboration: Give neutralizer	Nebulizier can dilute the secret and act as bronchodilators to widen the airway.
2.	Chest X-ray and do clapping or vibration	Knowing the location of secret
3.	Teach effective cough (in patients who did not experience a decrease in consciousness and is able to cough effectively).	Removing the secret of the airway especially in patients who did not experience a decrease disturbance of consciousness and can perform an effective cough.
4.	Observation of vital signs	To find out the healthy development of clients.

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Ineffective Airway Clearance related to - COPD

Nursing Diagnosis Ineffective airway clearance related to :

•  bronchoconstriction,
• increased mucus formation, 
• ineffective cough, 
• bronchopulmonary infection.

Goal: Achievement of client airway clearance

Nursing Interventions Ineffective airway clearance:

• Give the patient 6 to 8 glasses of fluid / day unless there is a cor pulmonale.
• Teach and give encouragement use of diaphragmatic breathing and coughing techniques.
• Assist in the provision of action nebulizer, metered dose inhalers.
• Perform postural drainage with percussion and vibration in the morning and evening according to the required.
• Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
• Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in sputum color, viscosity of sputum, increased shortness of breath, chest tightness, fatigue.
• Give antibiotics as required.
• Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

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Nursing Diagnosis Ineffective Airway Clearance - Pulmonary Tuberculosis

Nursing Diagnosis Ineffective Airway Clearance


related to:

• thick secretions or blood secretions,
• weakness,
• bad cough effort,
• edema, tracheal / pharyngeal.

Goal :

• Maintaining a patient's airway.
• Removing secretions without help.
• Demonstrate behaviors to improve airway clearance.
• Participate in treatment programs according to the conditions. Identify potential complications and appropriate action.

Nursing Interventions Ineffective Airway Clearance - Pulmonary Tuberculosis:

a. Assess respiratory function: breath sounds, speed, rhythm, depth and accessory muscle use.
Rationale: Decreased breath sounds indicate atelectasis, Ronchi indication of accumulation of secretions / inability of clearing the airway so that the accessory muscle use and increased work of breathing.

b. Note the ability to remove secretions or cough effectively, record the character, amount of sputum, presence of hemoptysis.
Rational: Expenditures difficult when thick secretions, sputum, bleeding from the bronchial lung damage or injury that requires evaluation / intervention information.

c. Give the patient or the semi-Fowler position, Help / teach effective coughing and breathing exercises.
Rationale: Increased lung expansion, maximum ventilation opening areas of atelectasis and increased secretions movement to be easily removed.

d. Clean secretions from the mouth and trachea, suction if necessary.
Rationale: To prevent obstruction / aspiration. Suction done when patients are unable to remove secretions.

e. Maintain a fluid intake of at least 2500 ml / day unless contraindicated.
Rationale: Helps thin the secretions so easily removed.

f. Moisten the air / oxygen inspiration.
Rationale: Prevents drying of mucous membranes.

g. Give medications: bronchodilators, corticosteroids as indicated.
Rational: Lowering the viscosity of secretions, circle trakeabronkial lumen size, handy in case of hypoxemia in a wide cavity.

h. Help incubation emergency if necessary.
Rational: It takes the rare cases bronkogenik. with laryngeal edema or acute pulmonary hemorrhage.

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