ncp for TB
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ASSESSME NT Objective - pale in appearance - dyspnea - uses accessory muscles when breathing - productive cough - RR=41 cycles per minute
DIAGNOS IS Ineffective airway clearance related to ineffective cough
After 8 hours of nursing intervention s, the patient's secretions will be mobilized and airway will show decreased in secretions
Independent: • Assess airway for patency.
• Auscultate lungs for presence of normal or adventitious breath sounds, as in the following: o Decreased or absent breath sounds o Wheezing o Coarse sounds
RATIONALE >Maintaining the airway is always the first priority, especially in cases of trauma, acute neurological decompensation, or cardiac arrest.
>These may indicate presence of mucus plug or other major airway obstruction. >These may indicate increasing airway resistance. >These may indicate presence of fluid along larger airways.
• Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing.
>Abnormality indicates respiratory compromise.
• Assess changes in mental status.
>Increasing lethargy, confusion, restlessness, and/or irritability can be early signs of cerebral hypoxia.
• Assess cough for effectiveness and productivity.
• Note presence of sputum; assess quality, color, amount, odor, and consistency.
>Consider possible causes for ineffective cough (e.g., respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions). >This may be a result of infection, bronchitis, chronic smoking, or other condition. A sign of infection is
EVALUATION Effectiveness - Was the patient able to maintain patent airway? -Was the patient able to mobilize her secretions? -Was the patient able to have patent airway? Adequacy -Was all the planned nursing interventions are enough in achieving and maintaining patent airway? -Was all the resources of the nurse like time and effort are enough? Appropriaten ess -Was the interventions mentioned are applicable and beneficial to the patient?
Acceptability - Was the family willfully accepted the interventions done to the patient.
• Assist patient in performing coughing and breathing maneuvers. • Instruct patient in the following: o Optimal positioning (sitting position) o Use of pillow or hand splints when coughing o Use of abdominal muscles for more forceful cough o Use of quad and huff techniques o Use of incentive spirometry o Importance of ambulation and frequent position changes
discolored sputum (no longer clear or white); an odor may be present. >These improve productivity of the cough.
>Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal pressure and upward diaphragmatic movement.
• Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation). • Encourage oral intake of fluids within the limits of cardiac reserve.
>These promote better lung expansion and improved air exchange.
• Demonstrate and teach coughing, deep breathing, and splinting techniques.
>Increased fluid intake reduces the viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner secretions with coughing.
Dependent: • Administer medications: o Mucolytics (e.g. Guaifenesin)
>Patient will understand the rationale and appropriate techniques to keep the airway clear of secretions.
o Bronchodilators (e.g. Albuterol) Collaborative: • Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and home care/rehabilitation environments).
>Relieves respiratory difficulties by hydrolyzing glycosaminoglycans, tending to break down/lower the viscosity of mucincontaining body secretions/compone nts, thereby dissolving thick mucus. >Reduces resistance in the respiratory airway and increases airflow to the lungs. >Chest physiotherapy includes the techniques of postural drainage and chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning.