Ineffective Airway Clearance Nursing Care Plan for Tetanus

Tetanus is caused by gram positive, obligate anaerobic bacteria: Clostridium tetani which affects skeletal muscles."Gram positive" means that the bacteria has a thick cell wall, while "obligate anaerobe" means that the bacteria can't survive in the presence of oxygen and survive using anaerobic respiration (without oxygen).

Causes:
Bacterium Clostridium tetani.
Contamination of a puncture wound, e.g.: a piercing.
Ear infections as bacteria may enter through ear.
Using unsterile equipment in surgery or other similarly invasive procedures such as tattooing and body piercing.

Ineffective Airway Clearance related to the accumulation of sputum in the trachea and the respiratory muscles spame

Characterized by:
Ronchi,
Cyanosis,
Dyspneu,
Ineffective cough accompanied by sputum or phlegm, lab test results, Abnormal Blood Gas Analysis (respiratory acidosis)

Objective: Airway clearance is effective

Criteria:

- Clients are not congested, mucus, or none sleam
- Respiratory 16 -18 x / minute
- No breathing nostril
- No additional respiratory muscle
- The results of laboratory examination of blood: Blood Gas Analysis in the normal range (pH = 7.35 to 7.45; PCO2 = 35-45 mmHg, pO 2 = 80-100 mmHg)

Nursing Interventions Ineffective Airway Clearance Nursing Care Plan for Tetanus:

1. Clear the airway by adjusting the position of head extension
Rational: The anatomy of the head position of the extension is a way to align the respiratory cavity so that the process of respiration remains smooth to get rid of airway obstruction.

2. Physical examination by auscultation listening to breath sounds (there Ronchi) every 2-4 hours.
Rational: Ronchi indicate a problem caused by upper respiratory fluids or secretions that covered most of the respiratory tract that is necessary to issue, to optimize the airway.

3. Clean the mouth and airways of secretions and mucus by suction
Rational: Suction is an act of assistance to remove secretions, thus simplifying the process of respiration.

4. oxygenation
Rationale: The provision of oxygen in adequat can supply and provide backup oxygen, thus preventing the occurrence of hypoxia.

5. Observation of vital signs every 2 hours
Rational: Dyspneu, cyanosis is a sign of breathing disorder which is accompanied by decreased cardiac work and capilary tachycardia arising refill time prolonged / long.

6. Observation of the onset of respiratory failure.
Rational: The inability of the body in the process of respiration required critical interventions using tools breathing (mechanical ventilation)

7. Collaboration in drug delivery thinning secretions
Rational: Drug-thinning secretions could dilute the thick secretions that facilitate spending and prevent viscosity.

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Ineffective Airway Clearance Stroke Nursing Care Plan

Ineffective Airway Clearance Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Stroke

Stroke is also Referred to as a brain attack, and it Occurs Pls a blood vessel leading to the brain ruptures or gets blocked due to plaque deposits. When plaque accumulates on the wall of arteries, it is known as arthrosclerosis.

Nanda Nursing Diagnosis Ineffective Airway Clearance

related to the buildup of sputum (due to weakness, loss of cough reflex)

Goal: Patient is able to maintain a patent airway.

Expected outcomes:

a. Vesicular breath sounds

b. Normal respiratory rate

c. No signs of cyanosis and pallor

d. There is no sputum

Nursing Interventions :

1. Auscultation of breath sounds

2. Measure vital signs

3. Give the semi-Fowler position in accordance with the requirements (not conflict with other nursing problems)

4. Perform the exploitation lenders and pairs of OPA if decreased consciousness

5. When it is possible to do chest physiotherapy and breathing exercises in

6. Collaboration:

• Provision of oxygenation
• Laboratory: blood gas analysis, complete blood etc.
• Giving medication as needed

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Ineffective Airway Clearance Nursing Care Plan for Epistaxis

Epistaxis, commonly known as nosebleeds, is a prevalent and usually benign condition that involves bleeding from the nasal passages. While often not serious, recurrent or prolonged nosebleeds may warrant attention. This article explores the causes, risk factors, and management strategies for epistaxis.

Causes of Epistaxis:

1. Trauma: The most common cause of nosebleeds is trauma to the delicate blood vessels in the nasal passages, often resulting from nose picking, forceful blowing, or injury.
2. Dry Air: Exposure to dry or low-humidity environments can lead to the drying and cracking of the nasal mucosa, increasing the risk of bleeding.
3. Nasal Irritation: Allergies, infections, or irritants like smoke and pollutants can irritate the nasal lining, making it more susceptible to bleeding.
4. Underlying Medical Conditions: Certain medical conditions, such as blood clotting disorders, hypertension, or hereditary hemorrhagic telangiectasia (HHT), may contribute to recurrent or severe nosebleeds.

Risk Factors for Epistaxis:

1. Age: Children and older adults are more prone to nosebleeds due to factors like fragile blood vessels in children and drying nasal tissues in the elderly.
2. Dry Climates: Living in regions with dry climates or during winter months when indoor heating reduces humidity increases the risk of epistaxis.
3. Nasal Trauma: Individuals involved in activities that may result in nasal trauma, such as contact sports or accidents, face an elevated risk of nosebleeds.

 

Nursing Diagnosis Nursing Care Plan for Epistaxis

Ineffective Airway Clearance

Ineffective airway clearance is a condition that impedes the proper removal of respiratory secretions, increasing the risk of airway obstruction and respiratory compromise. This article delves into the causes, symptoms, and management strategies for ineffective airway clearance.

Causes of Ineffective Airway Clearance:

1. Respiratory Infections: Conditions such as pneumonia, bronchitis, or the common cold can lead to increased mucus production, impairing the normal clearing of the airways.
2. Chronic Respiratory Diseases: Individuals with chronic conditions like chronic obstructive pulmonary disease (COPD) or cystic fibrosis may experience persistent difficulty in clearing respiratory secretions.
3. Neuromuscular Disorders: Conditions affecting the muscles or nerves involved in coughing and clearing the airways, such as muscular dystrophy or amyotrophic lateral sclerosis (ALS), can contribute to ineffective airway clearance.
4. Anesthesia or Sedation: During medical procedures requiring anesthesia or sedation, the natural reflexes for clearing the airway may be temporarily suppressed, leading to ineffective clearance.

Symptoms of Ineffective Airway Clearance:

1. Persistent Cough: A chronic or persistent cough, especially one that produces thick or colored mucus, can indicate difficulty in clearing the airways.
2. Shortness of Breath: Ineffective airway clearance can result in a feeling of breathlessness due to the accumulation of secretions in the respiratory passages.
3. Increased Respiratory Rate: Individuals may exhibit an increased respiratory rate as the body attempts to compensate for compromised airway clearance.
4. Wheezing or Noisy Breathing: Obstruction of the airways by secretions can lead to wheezing or other abnormal sounds during breathing.

Goal: to be effective airway clearance

Expected Outcomes: Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnoea and cyanosis does not occur.

Independent

• Assess the sound or the depth of breathing and chest movement.
  Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions.
• Note the ability to remove mucous / coughing effectively
  Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury.
• Give Fowler's or semi-Fowler position.
  Rational: Positioning helps maximize lung expansion and reduce respiratory effort.
• Clean secretions from the mouth and trachea
  Rational: To prevent obstruction / aspiration.
• Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated.
  Rational: Helping dilution of secretions.

Collaboration

• Give medication in accordance with the indications mucolytic, expectorant, bronchodilator.
  Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort.

 

Bibliography:

1. Biswas, D., & Davies, K. (2018). Assessment and management of epistaxis. InnovAiT, 11(11), 635-642. doi: 10.1177/1755738018774321
2. Shaheen, O. H., Burton, M. J., & Withers, S. J. (2019). Epistaxis. BMJ Clin Evid, 2019, 1307.
3. Pallin, D. J., Chng, Y. M., McKay, M. P., Emond, J. A., Pelletier, A. J., & Camargo, C. A. (2005). Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Annals of Emergency Medicine, 46(1), 77-81. doi: 10.1016/j.annemergmed.2004.12.026 
4. Hegland, K. W., Bolser, D. C., & Davenport, P. W. (2012). Volitional Airway Protection in Chronic Obstructive Pulmonary Disease. The Journal of Applied Physiology, 112(1), 129–141. doi: 10.1152/japplphysiol.00289.2011
5. Osadnik, C. R., McDonald, C. F., Miller, B. R., Hill, C. J., Tarrant, B., & Steward, R. (2017). The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re‐exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: A multicentre, randomised controlled trial. Thorax, 72(2), 137–144. doi: 10.1136/thoraxjnl-2016-208420
6. Winck, J. C., & Azevedo, L. F. (2014). Non-invasive ventilation in patients with chronic obstructive pulmonary disease with moderate hypoxaemia during air travel. Revista Portuguesa de Pneumologia (English Edition), 20(1), 22–26. doi: 10.1016/j.rppnen.2013.02.002

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Ineffective Airway Clearance NIC NOC

Ineffective Airway Clearance

Definition:

Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency.

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Ineffective airway clearance related to

• The accumulation of secretions
• Airway spasm

Data:

• Cough
• Discharge
• Dyspneu
• Cyanosis
• Respiratory rate increased
• Ronkhi
• Wheezing

a. Airway Management:

• Open the airway with headtilt, chinlift, jaw thrust
• Set the position to maximize ventilation
• Use tools airway
• Perform chest physiotherapy
• Teach breath deeply and cough effectively
• Perform suction
• Auscultation of breath sounds
• Give bronchodilators (Collaboration)

b. Oxygenation therapy

• Provide humidification system of oxygen equipment
• Monitor the flow of oxygen and the amount given
• Monitor signs of oxygen toxicity

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