NCP COPD - Ineffective Airway Clearance

Chronic obstructive pulmonary disease (COPD) also known as emphysema and chronic bronchitis is a very serious disease. COPD is one of the most common lung diseases.

There are two main forms of COPD:
Chronic bronchitis, which involves a long-term cough with mucus
Emphysema, which involves destruction of the lungs over time

Symptoms of COPD
Cough, with or without mucus
Many respiratory infections
Shortness of breath (dyspnea) that gets worse with mild activity
Trouble catching one's breath

In COPD, less air flows in and out of the airways because of one or more of the following:

The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which can clog them.

Nursing Care Plan for COPD

Nursing Diagnosis : Ineffective Airway Clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Expected outcome : Maintain a patent airway and breath sounds clean

Interventions :

Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress.
Help the abdominal breathing exercises or lip.
Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).
Increase fluid intake to 3000 ml / day according to tolerance of the heart.

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Nursing Care Plan