Nursing Diagnosis Analysis Goal & Objectives Interventions Rationale Evaluation

Ineffective airway Bronchiectasis is a Goal: After 8 hours of Independent Effectiveness:

clearance related to chronic, irreversible nursing intervention, the • Auscultate breath • The presence of After 8 hours of
retained dilation of the bronchi client will be able to sounds q 1 to 4 coarse crackles nursing
tracheobronchial and bronchioles. The maintain patent airway hours. Breath during late intervention, the
secretions inflammatory process as evidenced by sounds are normally inspiration indicates client was able to
associated with clear/clearing breath clear or scattered fluid in the airway; maintain patent
Cues: pulmonary infections sounds. fine crackles at wheezing indicates a airway as
I> damages the bronchial bases, which clear narrowed airway. evidenced by
• He complained, wall, causing a loss of with deep breathing. (Simpson, 2006) clear/clearing
“Ang hirap ilabas its supporting structure breath sounds.
nung plema, and resulting in thick • Monitor respiratory • A normal respiratory
parang matigas sputum that ultimately patterns, including rate for an adult Efficiency:
siya sa loob.” obstructs the bronchi. rate, depth, and without dyspnea is The interventions
The walls become effort. 12 to 20. With were done within
O> permanently distended secretions in the the time frame.
• At present, he and distorted, impairing Objectives: airway, the
still expectorates mucociliary clearance. After nursing respiratory rate will
sputum, however The inflammation and intervention, the client increase. (Simpson, Appropriateness:
it is lesser than infection extend to the will be able to: 2006) The interventions
before, no more peribronchial tissues; in were realistic for the
blood, but its the case of saccular • Assume an upright • Position the client to • An upright position client, the setting
color is still light bronchiectasis, each position optimize respiration allows for maximal and the time table.
yellow. dilated tube virtually lung expansion; lying
• The client’s amounts to a lung flat causes
provisional abscess, the exudate abdominal organs to Acceptability:
diagnosis is PTB which drains freely shift toward the The interventions
5 fibrothorax R through the bronchus. chest, which crowds were acceptable to
bronchiectasis, The retention of the lungs and makes the client and
and one of the secretions and it more difficult to significant others
manifestations of subsequent obstruction breathe. (Seckel,
this condition is ultimately cause the 2007)
having purulent alveoli distal to the Adequacy:
sputum. obstruction to collapse. Developmental All interventions
M> In time the patient were implemented
RR: 26 cpm develops respiratory • Restate importance • Encourage client to • Fluids help minimize accordingly.
insufficiency with of increase fluid intake mucosal drying and
reduced vital capacity, increasing fluid of up to 2500 maximize ciliary
decreased ventilation, intake
and an increased ratio mL/day within action to move
of residual volume to cardiac or renal secretions. (Smith-
total lung capacity. reserve. Sims, 2001)
There is impairment in • Restate the
the matching of importance of taking • Teach the client the • Taking the entire
ventilation to perfusion the entire course of need to take course of antibiotics
and hypoxemia. antibiotics ordered antibiotics helps to eradicate
Reference: Smeltzer, until prescription bacterial infection,
S. and Bare, B., has run out. which decreases
Brunner & lingering, chronic
Suddarth’s Textbook infection. (Donahue,
of Medical-Surgical 2002)
Nursing, 10th ed,
• Return demonstrate Supplemental
Vol.1, pp. 585-586
pursed-lip breathing • Teach the client on • Pursed lip breathing
how to do pursed-lip aims to prolong
breathing. exhalation and
• Demonstrate proper increase airway
pursed-lip breathing. pressure during
expiration, thus
reducing the amount
of trapped air and
the amount of airway
resistance.
(Smeltzer-Bare,
2004)

• Receive postural Dependent

drainage and • Provide postural • Chest physiotherapy,
percussion as drainage and including percussion
ordered by the percussion only as and postural
physician ordered by the drainage, is
physician. important in
secretion
management.
(Smeltzer-Bare,
2004)
• Receive due
medications, most • Administer • Mucolytics help to
specifically the mucolytics as per decrease the
mucolytics doctor’s order. viscosity of the
sputum and promote
 expectoration of
secretions.
(Smeltzer-Bare,
2004)

• Verbalize Collaborative
cooperation towards • Refer atypical • Maximizing nurse-
the referred health assessment findings physician
care provider to client’s attending collaboration holds
physician. promise for
improving patient
care and creating
satisfying work roles.
(www.medscape.co
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