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Saturday, January 21, 2012

Nursing Interventions for Ineffective Airway Clearance

Nursing Interventions for Ineffective Airway Clearance

Nursing Priority

NO.1 To maintain adequate, patent airway:
  1. Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
  2. Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
  3. Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
  4. Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
  5. Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
  6. Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
  7. Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
  8. Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.
  9. Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors.
  10. Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
  11. Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.

Nursing Priority

NO.2 To mobilize secretions:
  1. Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
  2. Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
  3. Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
  4. Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
  5. Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
  6. Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
  7. Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
  8. Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
  9. Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
  10. Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.

Nursing Priority

NO.3 To assess changes, note complications:
  1. Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.
  2. Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress.
  3. Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
  4. Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
  5. Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
  6. Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
  7. Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.

Nursing Priority

NO.4 To promote wellness (Teaching/Discharge Considerations):
  1. Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
  2. Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
  3. Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
  4. Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
  5. Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
  6. Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
  7. Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
  8. Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.
  9. Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association).
  10. Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)

Nursing Interventions for Ineffective Airway Clearance


Friday, January 20, 2012

Nursing Interventions for Risk for Injury

Risk for Injury

NANDA Definition:

The risk of injury as a result of the interaction of environmental conditions with individual adaptive response and defense sources.

Related To :
[Substance intoxication]
[Substance withdrawal]
[Psychomotor agitation]
[Unstable vital signs]
[Panic level of anxiety]

  • Short-Term Goal : Client’s condition will stabilize within 72 hours.
  • Long-Term Goal : Client will not experience physical injury.

Nursing Intervention for Risk for Injury

  1. Maintain a closed central IV system using Luer-Lok connections and taping of all connections. Rationale: Inadvertent disconnection of central IV system can result in lethal air emboli.
  2. Administer appropriate TPN solution via peripheral or central venous route, including peripherally inserted central catheter (PICC) lines and tunneled catheters. Rationale: Solutions containing high concentrations of dextrose more than 10% must be delivered via a central vein because they result in chemical phlebitis when delivered through small peripheral veins.
  3. Monitor for potential drug and nutrient interactions. Rationale: Various interactions are possible, such as digoxin in conjunction with diuretic therapy, which can cause hypomagnesemia; hypokalemia may result from chronic use of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.
  4. Assess catheter for signs of displacement out of central venous position: extended length of catheter on skin surface, leaking of IV solution onto dressing, client complaints of neck arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion. Rationale: Central venous catheter tip may slip out of superior vena cava and migrate into smaller innominate and jugular veins, causing a chemical thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased with extended use of central venous catheters.
  5. Inspect peripheral TPN catheter site routinely and change sites at least every other day or per protocol. Rationale: Peripheral TPN solutions, although less hyperosmolar, can still irritate small veins and cause phlebitis. Peripheral venous access is often limited in malnourished clients, but site should still be changed if signs of irritation develop.
  6. Investigate reports of severe chest pain or coughing in clients with central line. Turn client to left side in Trendelenburg position, if indicated, and notify physician. Rationale: Suggests presence of air embolus requiring immediate intervention to displace air into apex of heart away from the pulmonary artery.
  7. Maintain an occlusive dressing on catheter insertion sites for 24 hours after subclavian catheter is removed. Rationale: Extended catheter use may result in development of catheter skin tract. Once the catheter is removed, air embolus is still a potential risk until skin tract has sealed.

Monday, January 2, 2012

Herniated Nucleus Pulposus Nanda Nursing Interventions

Herniated Nucleus Pulposus

Intervertebral Discs are the cartilage plates that form a cushion between the vertebral bodies. Hard and fibrous material is combined in one capsule. Such as ball bearings in the middle of the disc called the nucleus pulposus. Herniated nucleus pulposus is a rupture of the nucleus pulposus.

Herniated nucleus pulposus into the vertebral bodies can be above or below it, can also directly into the vertebral canal.

Pain can occur in any part such as cervical spine, thoracic (rarely) or lumbar. Clinical manifestations depend on the location, speed of development (acute or chronic) and the effect on surrounding structures. Lower back pain is severe, chronic and recurring (relapse).

Intervention Nursing Care Plan for HNP Herniated Nucleus Pulposus

1. Acute pain related to nerve compression, muscle spasm

a. Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10
b. Maintain bed rest, semi-Fowler position to the spinal bones, hips and knees in a state of flexion, supine position
c. Use logroll (board) during a change of position
d. Auxiliary mounting brace / corset
e. Limit your activity during the acute phase according to the needs
f. Teach relaxation techniques
g. Collaboration: analgesics, traction, physiotherapy

2. Impaired physical mobility related to pain, muscle spasms, and damage neuromuskulus restrictive therapy

a. Give / aids patients to perform passive range of motion exercises and active
b. Assist patients in ambulation activity progressively
c. Provide good skin care, massage point pressure after rehap change of position. Check the state of the skin under the brace with a specific time period.
d. Note the emotional responses / behaviors in immobilizing
e. Demonstrate the use of auxiliary equipment such as a cane.
f. Collaboration: analgesic

3. Anxiety related to ineffective individual coping

a. Assess the patient's anxiety level
b. Provide accurate information
c. Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities.
d. Review of secondary problems that may impede the desire to heal and may hinder the healing process.
e. Involve the family

4. Knowledge deficient related to the lack of information about the condition, prognosis

a. Explain the process of disease and prognosis, and restrictions on activities
b. Give information about your own body mechanics to stand, lift and use the shoes backer
c. Discuss about treatment and side effects.
d. Suggest to use the board / mat is strong, a small pillow under your neck a little flat, bed side with knees flexed, avoid the tummy.
e. Avoid the use of heaters in a long time
f. Give information about the signs that need attention such as puncture pain, loss of sensation / ability to walk.

Source :