Nanda Nursing Diagnosis

Nursing Care Plan for Bronchiectasis Bronchiectasis is a chronic dilatation of the bronchi and bronchioles that may be caused by various conditions, including lung infections and bronchial obstruction; foreign body aspiration, vomit, and objects from the upper respiratory tract; and the pressure due to a tumor, blood vessels dilated and enlarged lymph nodes (Brunner & Suddart, 2002). According Suyono (2001) etiology of bronchiectasis are: 1. Infection Bronchiectasis often occur after a child suffering from pneumonia who frequently relapse and long lasting. Pneumonia is generally a pertussis or influenza complications suffered during the child, pulmonary tuberculosis, and so on. 2. Abnormalities hereditary or congenital abnormalities In this case bronchiectasis occurs in the womb. Genetic factors or growth factors and fetal development plays an important role. Usually has the characteristics on almost all branches of the bronchi in the lungs one or two. Usually accompanied by other ...

Nursing Care Plan for Hyperthyroidism : Ineffective Airway Clearance and Knowledge Deficit Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often referred to as an "overactive thyroid." Symptoms Difficulty concentrating, Fatigue, Frequent bowel movements, Goiter (visibly enlarged thyroid gland) or thyroid nodules, Heat intolerance, Increased appetite, Increased sweating, Irregular menstrual periods in women, Nervousness, Restlessness, Weight loss (rarely, weight gain) Other symptoms that can occur with this disease: Breast development in men, Clammy skin, Diarrhea, Hair loss, Hand tremor, High blood pressure, Itching - overall, Lack of menstrual periods in women, Nausea and vomiting, Pounding, rapid, or irregular pulse, Protruding eyes (exophthalmos), Rapid, forceful, or irregular heartbeat (palpitations), Skin blushing or flushing, Sleeping difficulty, Weakness Nursing Diagnosis : Ineffective Airway Clearance related ...

Nursing Diagnosis Care Plans for Bronchiectasis : Ineffective Airway Clearance Ineffective airway clearance related to increased production of secretions, viscous secretions. Purpose: Maintains a patent airway with breath sounds clean. Expected outcomes: Showed behavior to improve airway clearance (effective cough, and issued a secret. Plan of Action: 1. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration. R /: tachypnea common to some degree can be found at the reception or during stress / acute infection process. Breathing slows down and the frequency of expiratory elongated than inspiration. 2. Auscultation of breath sounds and note the presence of breath sounds. R /: The degree of bronchial spasms occur with airway obstruction and may / not manifested any breath sounds. 3. Assess the patient to a comfortable position, Height head of the bed and sat on the back of the bed. R /: bed head elevation facilitate respiratory function by using gravity. And ...

Nursing Diagnosis: Ineffective Airway Clearance NANDA 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. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] ...

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...