1 Ineffective Airway Clearance

COPD is an inIlammatory response to the oIIending microorganism. The deIense mechanisms oI

the lungs lose eIIectiveness and allow organisms to penetrate the sterile respiratory tract, as a
result inIlammation develops. The inIlammation and increased secretions make it diIIicult to
maintain a patent airway.
Assessment
Nursing
Diagnosis
Planning
Nursing Inter-
ventions
Rationale
Expected
Outcome
S:O: The may
patient maniIest
the IIg.:~with
wheezes/crackle
s upon
auscultation on
the BLF
~with subcostal
retraction
~with nasal
Ilaring
~presence oI
non-productive
cough
~increase RR
above normal
range
IneIIectiv
e airway
clearance
related to
retained
and
excessive
secretions
and
ineIIective
coughing
Short
term:AIter 4-5
hours oI
nursing
interventions
the patient will
demonstrate
eIIective
clearing oI
secretions.Lon
g term:AIter 2
days oI nursing
interventions,
the patient will
maintain
eIIective
airway
clearance.
~Establish rapport
to the pt. and
SO~Assess the
patient
condition~Monito
r and record
V/S~Position head
midline with
Ilexion on
appropriate Ior
age/condition
~Elevate HOB
~Observe S/Sx oI
inIections
~Auscultate
breath sounds &
assess air mov`t
~Instruct the
patient to increase
Iluid intake
~Demonstrate
eIIective coughing
and deep-
breathing
techniques.
~Keep back dry
~Turn the patient
q 2 hours
~To gain trust
and active
participation~T
o know the
condition oI the
pt~To have a
baseline
data.~To gain or
maintain open
airway
~To decrease
pressure on the
diaphragm and
enhancing
drainage
~To identiIy
inIectious
process
~To ascertain
status & note
progress
~To help to
liqueIy
secretions.
~To maximize
eIIort
~To prevent
Iurther
complications
~To prevent
Short
term:The
patient shall
have
demonstrated
eIIective
clearing oI
secretions.Lon
g term:The
patient shall
have
maintained
eIIective
airway
clearance.
~Demonstrate
chest
physiotherapy,
such as bronchial
tapping when in
cough, proper
postural drainage.
~Administer
bronchodilators
iI prescribed.
possible
aspirations
~These
techniques will
prevent possible
aspirations and
prevent any
untoward
complications
~More
aggressive
measures to
maintain airway
patency.
Ineffective Breathing Pattern
The presence oI microorganisms in the lungs causes body to increase the secretory activity oI
goblet cells to get rid oI the invading organism but the mechanism is not enough which allows
the stasis oI mucus secretion leading to ineIIective breathing pattern.
Assessment
Nursing
Dx
Planning
NursingInter-
ventions
Rationale
Expected
Outcome
S: Reports
oI
dyspneaO:
The patient
may
maniIest
the
maniIest
the IIg.:~
with
wheezes
/crackles
upon
auscultation
on BLF~
increase RR
above
normal
range
IneIIective
breathing
pattern
related to
retained
mucus
secretions
Short
term:AIter
4-5 hours oI
nursing
interventions
the patient
will improve
breathing
pattern.Long
term:AIter 2
days oI
nursing
interventions
the patient
will
maintain a
respiratory
rate within
normal
limits.
~Establish rapport
to the pt. and
SO~Assess the
patient
condition~Monitor
and record V/S
especially
RR~Provide rest
periods
~Place pt in semi-
Iowlers position
~Increase Iluid
intake
~Keep patient
back dry
~Change position
~To gain trust
and active
participation~To
know the
condition oI the
pt~To have a
baseline
data.~To reduce
Iatigue and
obtain rest
~To have a
maximum lung
expansion
~To liqueIy
secretions
~To avoid stasis
oI secretions
Short
term:The
patient shall
have
improved
breathing
pattern.Long
term:The
patient shall
have
maintained a
respiratory
rate within
normal
limits.
~presence
oI
productive
cough
~use oI
accessory
muscle
when
breathing
~presence
oI nasal
Ilaring and
retractions
every 2 hours
~PerIorm CPT
~Place a pillow
when the client is
sleeping
~Instruct how to
splint the chest
wall with a pillow
Ior comIort during
coughing and
elevation oI head
over body as
appropriate
~Maintain a patent
airway, suctioning
oI secretions may
be done as ordered
~Provide
respiratory
support. Oxygen
inhalation is
provided per
doctor`s order
~Administer
prescribed cough
suppressants and
analgesics and be
cautious, however,
because opioids
may depress
respirations more
than desired.
and avoid
Iurther
complication
~To Iacilitate
secretion mov`t
and drainage
~To loosen
secretion
~To provide
adequate lung
expansion while
sleeping.
~To promote
physiological
ease oI maximal
inspiration
~To remove
secretions that
obstructs the
airway
~To aid in
relieving patient
Irom dyspnea
~To promote
deeper
respirations and
cough
Impaired Gas Exchange
The disruption oI the mechanical deIenses oI cough and ciliary motility leads to colonization oI
the lungs and subsequent inIection leading to inIlammation and accumulation oI secretions.
InIlamed and Iluid-Iilled alveolar sacs cannot exchange oxygen and carbon dioxide eIIectively.
Assessment
Nursing
Dx
Planning
NursingInter-
ventions
Rationale
Expected
Outcome
S:O: The
patient may
maniIest the
IIg.:~Appearance
oI bluish
extremities when
in cough
(cyanosis),
lips~Lethargy
~Restlessness
~Hypercapnea
~Hypoxemia
~Abnormal rate,
rhythm, depth oI
breathing
~Diaphoresis
Impaired
gas
exchange
related to
altered
oxygen
Short
term:AIter
4-5 hours oI
nursing
interventions
the patient
will improve
ventilation
and
adequate
oxygenation
oI
tissuesLong
term:AIter 2
days oI
nursing
interventions
the patient
will
minimize or
totally be
Iree oI
symptoms oI
respiratory
distress.
~Establish rapport
to the pt. and
SO~Assess the
patient
condition~Monitor
and record
V/S~Monitor level
oI consciousness
or mental status
~Assist the client
into the High-
Fowlers position
~Increase patient`s
Iluid intake
~Encourage
expectoration
~Encourage
Irequent position
changes
~Encourage
adequate rest &
limit activities to
within client
tolerance
~Promote
calm/restIul
environments
~Administer
supplemental
oxygen
judiciously as
indicated
~Administer meds
as indicated such
as bronchodilators
~To gain trustand
active
participation~To
know the condition
oI the pt~To have
a baseline data.
~Restlessness,
anxiety,
conIusion,
somnolence are
common
maniIestation oI
hypoxia and
hypoxemia.
~The upright
position allows Iull
lung excursion and
enhances air
exchange
~To help liqueIy
secretions
~To eliminate
thick, tenacious,
copious secretions
which contribute
Ior the impairment
oI gas exchange.
~To promote
drainage oI
secretions
~Helps limit
oxygen
needs/consumption
~To
Short
term:The
patient shall
have
improved
ventilation
and
adequate
oxygenation
oI
tissuesLong
term:The
patient shall
have
minimized
or totally be
Iree oI
symptoms
oI
respiratory
distress.
correct/improve
existing
deIiciencies
~May correct or
prevent worsening
oI hypoxia.
~To treat the
underlying
condition
Sleep Pattern Disturbance
COPD patients need a comIortable position such as the High-Fowler`s position during sleeping
in order to promote lung expansion. Lying Ilat on bed promotes the occurrence oI DOB and
makes the patient uncomIortable due to the impaired alveolar ventilation which the body
processes at night can`t be controlled
Assessment
Nursing
Dx
Planning
NursingInter-
ventions
Rationale
Expected
Outcome
S:O: The patient may
maniIest the
IIg.:~irritability~restlessn
ess
~lethargy
~changes in posture
~diIIiculty oI breathing
which worsens at night
Sleep
pattern
disturban
ce related
to
diIIiculty
oI
breathing
Short
term:AIter
4-5 hours oI
nursing
intervention
s the patient
will identiIy
individually
appropriate
intervention
s to promote
sleep.Long
term:AIter 2
days oI
nursing
intervention
s, the patient
will be able
to report
improvemen
ts in
sleep/rest
pattern.
~Establish
rapport to the pt.
and SO~Assess
the patient
condition~Monit
or and record
V/S~Monitor
level oI
consciousness or
mental status
~Promote
comIort
measures such
as back rub and
change in
position as
necessary
~Observe
provision oI
emotional
support
~To gain trust
and active
participation~T
o know the
condition oI the
pt~To have a
baseline
data~Restlessne
ss, anxiety,
conIusion,
somnolence are
common
maniIestation oI
hypoxia and
hypoxemia.
~To provide
non
pharmagcologic
management
~Lack oI
knowledge and
Short
term:The
patient shall
have
identiIied
individually
appropriate
intervention
s to promote
sleepLong
term:The
patient shall
have
reported
improvemen
ts in pt.`s
sleep/rest
~Provide quiet
environment.
~Increase
patient`s Iluid
intake
~Encourage
expectoration
~Limit the Iluid
intake in
evening iI
nocturia is a
problem
~Obtain
Ieedback Irom
SO regarding
usual bedtime,
rituals/routines
~Provide saIety
Ior patient sleep
time saIety
~Recommend
midmorning nap
iI one required
~Administer
pain medication
as ordered.
problems,
relationships
may create
tension.
InterIering with
sleep routines
based on adult
schedules may
not meet child`s
needs.
~To promote an
environment
conducive to
sleep.
~To help
liqueIy
secretions
~To eliminate
thick, tenacious,
copious
secretions which
contribute Ior
the DOB
~To reduce
need Ior
nighttime
elimination
~To determine
usual sleep
patterns &
provide
comparative
baseline
~To promote
comIort/saIety
~Napping esp.
in the aIternoon
can disrupt
normal sleep
pattern
~To relieve
discomIort and
take maximum
advantage oI
sedative eIIect
Risk for Spread of Infection
Once the bacteria, virus, or Iungus enter the lungs, they usually settle in the air sacs oI the lung
where they rapidly grow in number. This area oI the lung then becomes Iilled with Iluid and pus
as the body attempts to Iight the inIection. Disruption oI the mechanical deIenses oI cough and
ciliary motility leads to colonization oI the lungs and subsequent inIection
Assessment
Nursing
Dx
Planning
NursingInter-
ventions
Rationale
Expected
Outcome
S:O: The patient
may
maniIest:~Body
temperature above
normal
range~dehydration
~increase WBC
count
~presence oI
increase mucus
production
Risk Ior
spread oI
inIection
related to
stasis oI
secretions
and
decreased
ciliary
action.
Short
term:AIter 4-
5 hours oI
nursing
interventions
the patient
will identiIy
interventions
to prevent
and/or reduce
the risk oI
inIectionLong
term:AIter 2
days oI
nursing
interventions
the patient
will have
minimize or
totally be Iree
Irom the risk
oI inIection.
~Establish rapport
to the pt. and
SO~Assess the
patient
condition~Monitor
& record
V/S~Review
importance oI
breathing
exercises,
eIIective cough,
Irequent position
changes, and
adequate Iluid
intake
~Turn the patient
q 2 hours
~Encourage
increase Iluid
intake
~Stress the
importance oI
handwashing to
SO`s
~To gain trust and
active
participation~To
know the condition
oI the pt~To have
a baseline data and
Iever may be
present because oI
inIection and/or
dehydration~These
activities promote
mobilization and
expectoration oI
secretions to
reduce the risk oI
developing
pulmonary
inIection.
~To Iacilitate
secretion mov`t
and drainage
~To liqueIy
secretions
~Handwashing is
the primary
Short
term:The
shall have
identiIied
interventions
to prevent
and/or reduce
the risk oI
inIectionLong
term:The
patient shall
have
minimized or
totally be Iree
Irom the risk
oI inIection.
~Teach the SO`s
how to care Ior
and clean
respiratory
equipment
~Teach the SO`s
the maniIestations
oI pulmonary
inIections (change
in color oI sputum,
Iever, chills) , selI-
care and when to
call the physician
~Recommend
rinsing mouth with
water
~Administer
antimicrobial such
as ceIuroxime as
indicated.
deIense against the
spread oI inIection
~Water in
respiratory
equipment is a
common source oI
bacterial growth
~Early recognition
oI maniIestations
can lead to a rapid
diagnosis.
~To prevent risk
oI oral candidiasis.
~Given
prophylactically to
reduce any
possible
complications
Other nursing diagnoses:
O High risk Ior suIIocation
O High risk Ior aspiration
O Anxiety RT acute breathing diIIiculties
O Activity Intolerance RT inadequate oxygenation
O Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea
(Ior empysema)
Once the bacteria, virus, or Iungus enter the lungs, they usually settle in the air sacs oI the lung where they
rapidly grow in number. This area oI the lung then becomes Iilled with Iluid and pus as the body attempts to
Iight the inIection. Disruption oI the mechanical deIenses oI cough and ciliary motility leads to colonization oI
the lungs and subsequent inIection