Thursday, May 17, 2012

Ineffective Airway Clearance of COPD

Ineffective Airway Clearance Definition: The inability to clear secretions or obstruction of the respiratory tract to maintain airway hygiene.

Limitation of Characteristics:
  • Dyspnoea, decrease in breath sounds
  • Orthopneu
  • Cyanosis
  • Abnormalities of breath sounds (rales, wheezing)
  • Difficulty speaking
  • Cough, ineffective or no
  • Eyes widened
  • Production of sputum
  • Fidget
  • Changes in frequency and rhythm of the breath

Related factors:
  • 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

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