Limitation of Characteristics:
- Dyspnoea, decrease in breath sounds
- Abnormalities of breath sounds (rales, wheezing)
- Difficulty speaking
- Cough, ineffective or no
- Eyes widened
- Production of sputum
- Changes in frequency and rhythm of the breath
- Environment: smoking, tobacco smoke, passive smoking, infection
- Physiological: neuromuscular dysfunction, hyperplasia of the bronchial wall, airway allergy, asthma.
- Obstruction of the airway: airway spasm, secretion retention, the amount of mucus, the artificial airway, bronchial secretions, presence of exudate in the alveoli, the presence of foreign bodies in the airway.
NOC - Ineffective Airway Clearance of COPD:
- Respiratory status: Ventilation
- Respiratory status: Airway patency
- Aspiration control
Expected outcomes are:
- Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
- Showed a patent airway (the client does not feel suffocated, breath rhythm, respiratory frequency in the normal range, there is no abnormal breath sounds)
- Able to identify and prevent factors that can inhibit airway.
NIC - Ineffective Airway Clearance of COPD :
(1) Airway Suction
- Make sure the needs of oral / tracheal suctioning
- Auscultation of breath sounds before and after suctioning.
- Inform the client and family about suctioning
- Ask the client to do a deep breath before suction.
- Give oxygen using nasal to facilitate suksion nasotrakeal
- Use sterile tools that every action
- Instruct the patient to rest and breathe in after the catheter removed from nasotrakeal
- Monitor patient's oxygen status
- Teach the family how to perform suction
- Stop suksion and give oxygen if the patient showed bradycardia, increased oxygen saturation, etc..
(2) Airway Management
- Open the airway, chin lift technique guanakan or jaw thrust if necessary
- Position the patient to maximize ventilation
- Identify the patient's need for the installation of an artificial airway device
- Replace the mayo if needed
- Perform chest physiotherapy if necessary
- Remove secretions by coughing or suctioning
- Auscultation of breath sounds, note the presence of additional noise
- Apply suction to the mayo
- Give bronchodilators if necessary
- Provide NaCl humidifiers Damp wet gauze
- Adjust intake to optimize fluid balance.
- Monitor respiration and oxygen status