Friday, March 23, 2012

NIC NOC - Ineffective airway clearance related to Pleural effusion

Pleura Effusion NIC NOC - Ineffective airway clearancePleural effusion is an abnormal accumulation of fluids in the pleural space Between the parietal and visceral pleura of the Lungs. Breathlessness, chest pain and non-productive cough are the most common symptoms associated with pleural effusion.

Nursing Diagnosis and Interventions for Pleural effusion

Nursing Diagnosis: Ineffective airway clearance related to weakness and poor cough effort.

NOC:

• Demonstrate effective airway clearance and respiratory status evidenced by, gas exchange and ventilation are not dangerous:
- Having a patent airway
- Removing secretions effectively.
- Having a rhythm and respiratory frequency in the normal range.
- Having a pulmonary function within normal limits.

• Demonstrate adequate gas exchange, characterized by:
- Easy to breathe
- There is no anxiety, cyanosis and dyspnea.
- O2 saturation within normal limits
- Chest X-ray within the expected range.

NIC:
• Assess and document
- The effectiveness of the administration of oxygen and other treatments.
- The effectiveness of treatment.
- Trends in arterial blood gases.
• Auscultation of the anterior and posterior chest to find a decrease or absence of ventilation and the presence of noise barriers.
• Sucking airway
- Determine the need for oral suction / tracheal.
- Monitor the status of oxygen and hemodynamic status and cardiac rhythm before, during and after exploitation.
• Maintain adequacy of hydration to decrease viscosity of secretions.
• Explain the use of ancillary equipment properly, such as oxygen, suction equipment lenders.
• Inform the patient and family that smoking is an activity that is prohibited in the treatment room.
• Instruct the patient about the coughing and deep breathing techniques to facilitate the discharge of secretion.
• Negotiate with the respiratory therapist as needed.
• Give oxygen that has been humidified.
• Tell your doctor about the results of an abnormal blood gas analysis.
• Assist in the delivery of aerosol. Nebulizer and another lung treatment in accordance with institutional policies and protocols.
• Encourage physical activity to improve the movement of secretions.
• If the patient is unable to ambulate, the patient lies sleeping position changed every 2 hours.
• Inform the patient before beginning the procedure to reduce anxiety and increase self-control.

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