Nanda Nursing Diagnosis

Definition A situation in which individuals experienced a real threat or risk of respiratory status in relation to the inability to effectively cough. Related Factors: Decreased energy and fatigue Ineffective cough Tracheobronchial infection Tracheobronchial obstruction (including foreign body aspiration) Copious tracheobronchial secretions Perceptual/cognitive impairment Impaired respiratory muscle function Trauma Major Data Ineffective cough or no cough The inability to remove airway secretions. Minor Data Abnormal breath sounds The frequency, depth of abnormal breathing rhythm Expected Outcomes Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths. Nursing Intervention Nursing Care Plan for Ineffective Airway Clearance Assess airway for patency. Maintaining the airway is always the first priority , especially in cases of trauma, a...

Definition : Ineffective Breathing Pattern Circumstances where an individual suffered actual loss of ventilation or the risks associated with changes in breathing patterns. Related Factors: Inflammatory process: viral or bacterial Hypoxia Neuromuscular impairment Pain Musculoskeletal impairment Tracheobronchial obstruction Perception or cognitive impairment Anxiety Decreased energy and fatigue Decreased lung expansion Nursing Care Plan for Ineffective Breathing Pattern Major Data Changes in frequency or pattern of breathing (from the baseline value) Changes in pulse Minor Data Orthopnea, Tachypnoea, hiperpnea, hyperventilation. Respiratory dysrhythmias Breathing is difficult / respiratory careful. Expected Outcomes Individuals will: Demonstrate effective breathing frequency, and having gas exchange in the lungs. Stating the factors that cause, if known, and expressed adaptive ways to overcome these factors. Nursing Intervention Nursing Care Plan for Ineffective Breathing Pattern Make ...