Nursing Care Plan for Bronchiectasis

Nursing Care Plan for Bronchiectasis

Bronchiectasis

Bronchiectasis is destruction and widening of the large airways.

• If the condition is present at birth, it is called congenital bronchiectasis.


• If it develops later in life, it is called acquired bronchiectasis.

Causes

Bronchiectasis is often caused by recurrent inflammation or infection of the airways. It most often begins in childhood as a complication from infection or inhaling a foreign object.

Cystic fibrosis causes about half of all bronchiectasis in the United States. Recurrent, severe lung infections (pneumonia, tuberculosis, fungal infections), abnormal lung defenses, and obstruction of the airways by a foreign body or tumor are some of the risk factors.

The condition can also be caused by routinely breathing in food particles while eating.

Symptoms

Symptoms often develop gradually, and may occur months or years after the event that causes the bronchiectasis.

They may include :

• Bluish skin color


• Breath odor


• Chronic cough with large amounts of foul-smelling sputum


• Clubbing of fingers


• Coughing up blood


• Cough that gets worse when lying on one side


• Fatigue


• Paleness


• Shortness of breath that gets worse with exercise


• Weight loss


• Wheezing

www.nlm.nih.gov

Assessment

1. History or presence of supporting factors
   
   
   
   • Smoking
   
   
   • Living or working in areas with severe air pollution
   
   
   • History of allergies in the family
   
   
   • There is a history of acid in childhood.
   
   
   
   


2. History or the presence of trigger factors such exacerbations :
   
   
   
   • Allergen (pollen, dust, skin, pollen or fungal)
   
   
   • Emotional Sress
   
   
   • Excessive physical activity
   
   
   • Air pollution
   
   
   • Respiratory tract infections
   
   
   • The failure of the recommended treatment program
   
   
   
   
   


3. Physical examination by focusing on the respiratory system include :
   
   
   
   • Assess the frequency and respiratory rhythm
   
   
   • Inpeksi color of skin and mucosal color menbran
   
   
   • Auscultation of breath sounds
   
   
   • Make sure that when patients use accessory muscles when breathing :
     
     
     
     • Lifting the shoulders during breathing
     
     
     • retraction abdominal muscles during breathing
     
     
     • Respiratory nostril
     
     
     
     
   
   
   • Assess if the symmetrical or asymmetrical chest expansion
   
   
   • Assess if the chest pain on breathing
   
   
   • Assess cough (whether productive or nonproductive). When you specify the color of sputum productive.
   
   
   • Determine if the patient has dispneu or orthopneu
   
   
   • Assess the level of consciousness.
   
   
   
   

Nursing Diagnosis and Intervention

1. Ineffective airway clearance related to increased production of viscous secretions or secretion.
   

   Goal :
   Keep the airway patent with breath sounds clean / clear.

   
   

   Result Criteria :
   Showed the behavior to improve airway clearance (effective cough, and issued a secret.

   
   

   Action Plan :

   
   
   
   
   • Monitor the frequency of respiration. Note the ratio of inspiration and expiration.
   
   
   • Auscultation of breath sounds and record breath sounds.
   
   
   • Assess the patient to a comfortable position, height headboard and sat on the back of the bed.
   
   
   • Help the abdominal breathing exercise or lip.
   
   
   • Observations karakteriktik cough and Auxiliary measures for effectiveness cough efforts.
   
   
   • Depth of fluid intake till 3000ml/day appropriate cardiac tolerance and provide a warm and fluid intake between meals in lieu.
   
   
   • Give the drug as indicated.
   
   
   
   


2. Changes in nutrition less than body requirements related to nausea, vomiting, sputum production, dispneu.
   

   Goal :
   Improvement in nutritional status and body weight patients

   
   

   Result Criteria :
   Patients did not experience further weight loss or maintain weight.

   
   

   Plan of action :

   
   
   
   
   • Monitor input and output every 8 hours, the amount of food consumed and body weight are weighed each week.
   
   
   • Create a fun atmosphere, an environment free of odor during mealtimes.
   
   
   • Refer patient to a dietitian to monitor food plan that will be consumed.
   
   
   • Encourage clients to drink at least 3 liters of fluid per day, if not get an IV.