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Ineffective Airway Clearance and Activity Intolerance - NCP for Atelectasis

Nursing Diagnosis and Interventions for Atelectasis

Atelectasis is lung development is not perfect. Atelectasis is not actually a disease but is related to pulmonary parenchymal disease.

Clinical Manifestations
  • May not experience symptoms.
  • Mild shortness of breath: when is advanced in which up to half a lung inflammatory infiltration.
  • Cough: is due to the irritation of the bronchi, coughing is to throw / pull production inflammation, starting from a dry cough up purulent cough (produces sputum).
  • Chest pain: This is rare, occurs when the infiltration of inflammatory pain up to the pleura, giving rise to pleurisy.
  • Malaise: is found in the form of anorexia, decreased appetite, weight loss, headache, muscle aches, sweating at night time.
  • Tachycardia.
  • Cyanosis.
  • Heat or high temperature: subfebril, febrile (38-40 0C) intermittent.
  • Shock or loss of consciousness.
  • The location of the diaphragm will be elevated, reduced chest movement on the affected side.
  • May limit the heart and mediastinum will shift towards the sick.
  • Dullness or flat on the side that suffered atelectasis.
  • Additional breath sounds (crackles).
  • In broad atelectasis noisy breath weakened or no sound at all.
  • There are differences in the thoracic wall motion, the motion between the ribs and diaphragm. In the normal movement of the chest will tune during inspiration and expiration, but the client atelectasis chest movement on the affected side will be left of the chest movement on the healthy side.

Nursing Diagnosis for Atelectasis  : Ineffective Airway Clearance related to bronchial obstruction by mucus clot or foreign body

Characterized by:
  • Ineffective cough.
  • Secretions can not get out.
  • Additional breath sounds (eg crackles).
  • Increased RR, rapid and shallow breaths.

Goal:
Exhibit a client achieve airway clearance

Outcomes:
  • Clients can implement an effective cough.
  • Secretions can be removed.
  • Showed an increase in air exchange in the lungs.

Intervention:

1. Instruct clients to perform effective cough right:
  • Breath deeply and slowly as possible while sitting if able.
  • Use respiratory diaphragm.
  • Hold breath for 3-5 seconds and then exhale slowly through the mouth.
  • Take a second breath, hold it, and with a strong cough from the chest (use two short coughs really strong).
2. Maintain proper body position with.
3. Assist clients to dispense with the method of physiotherapy airway secretions (klepping, vibrating, or postural drainage).
4. Breaks Plan period (after coughing, before eating).
5. Guided and motivated clients to implement effective cough.
6. Collaboration with doctors for giving bronchodilators and suction (for spending secretions).
7. Record sputum characteristics (amount, color, odor).
8. Assess whether the client still feels pain.
9. Observation additional sound in the lungs, decreased chest wall expansion.


Nursing Diagnosis for Atelectasis  : Activity Intolerance related to impaired O2 transport system secondary to atelectasis

Characterized by:
  • Malaise.
  • Clients say have a headache / dizziness.
  • Increased RR.
  • Increased pulse rate.
  • Cyanosis.
Goal:
Clients can perform the activity on the bed.

Outcomes:
  • After minimal activity (in bed), the client shows:
  • RR and pulse frequency are within normal limits.
  • Headache / dizziness that is felt to have diminished or disappeared.

Intervention:

1. Encourage clients to be aware and controlled breathing (diaphragmatic breath and breathing lips) during increased activity and time of emotional and physical stress.
  • Breath lips: the client should breathe in through your nose and then exhale slowly through the mouth slightly open.
  • Breath diaphragm: nurse lay hands on the abdomen below the ribs basis and remain in place while the client to breathe air. For inhalation, the client should relax your shoulders, inhale through the nose, stomach and push against the hand of a nurse, hold the breath for 1-2 seconds to keep the alveoli open, then exhale slowly through the mouth.
2. Motivate the client to keep the airway activities several times each hour.
3. Encourage an increase in the daily activities on the client gradually to prevent lung paralysis.
4. Monitor client's response to the activity:
Measure vital signs immediately after the activity (pulse and RR).
Rest client for 3 minutes and then re-measure the vital signs.
Reduce the intensity, frequency, or duration of activity if the breath frequency increases after excessive activity.
READ MORE - Ineffective Airway Clearance and Activity Intolerance - NCP for Atelectasis

Excess Fluid Volume, Activity Intolerance and Risk for Infection - NCP for Cushing's Syndrome


Nursing Care Plan for Cushing's Syndrome


Nursing Diagnosis : Excess Fluid Volume related to excessive secretion of cortisol due to sodium and fluid retention.

Goal: The client shows the volume of fluid balance.

Intervention:
1. Measure intake output.
2. Avoid excessive fluid intake when the patient's hypernatremia.
3. Measure vital signs (BP, pulse, RR) every 2 hours.
4. Measure weight.
5. Monitor ECG for abnormalities (electrolyte imbalance).
6. Collaboration lab results (electrolytes: Na, K, Cl).

Rationale :
1. Shows the status of the transfer fluid circulating volume and response to pain.
2. Provide some sense of control in the face of attempts restriction.
3. Increased blood pressure, increased pulse and respiratory rate decreases indicate excess fluid.
4. Changes in body weight showed impaired fluid balance.
5. Hypernatremia and hypokalemia showed indications of excess fluid.
6. Shows fluid retention and should be limited.


Nursing Diagnosis : Activity Intolerance related to muscle weakness and changes in protein metabolism.

Goal: The client showed activity returned to normal after the act of nursing

Nursing Intervention :
1. Assess client's ability to perform activities.
2. Increase bed rest / sit.
3. Note the response to activities such as tachycardia, dyspnea, fatigue.
4. Increase active involvement of the patient in accordance with his ability.
5. Provide assistance activities as needed.
6. Provide appropriate entertainment activities such as watching TV and listening to radio.

Rationale :
1. Knowing the client's level of development activity.
2. Periods of rest are energy saving techniques.
3. Response showed an increase in O2, fatigue and weakness.
4. Adding a level of confidence and self-esteem of patients both in abundance according to the level of activity is tolerated.
5. Meet the needs of client activity.
6. Increase relaxation and energy savings, refocus and improve coping.


Nursing Diagnosis : Risk for Infection related to a decrease in immune response, inflammatory response.

Goal: Infection does not occur after the intervention.

Nursing Intervention :
1. Assess for signs of infection.
2. Measure vital signs every 8 hours.
3. Wash hands before and after nursing action.
4. Restrict visitors as indicated.
5. Place the client in isolation as indicated.
6. Antibiotics as indicated.

Rationale :
1. Presence of signs of infection (tumor, rubor, dolor, calor, functionalist laesa) is an indicator of infection.
2. Temperature increased an indicator of infection.
3. Prevent cross infection.
4. Reducing Exposure to other infectious pathogens.
5. Isolation techniques may be needed to prevent the spread / protect other patients from infection process.
6. Antibiotic therapy to reduce the risk of nosocomial infection.
READ MORE - Excess Fluid Volume, Activity Intolerance and Risk for Infection - NCP for Cushing's Syndrome

Fluid and Electrolyte Imbalances related to Addison's Disease

Nursing Diagnosis for Addison's Disease : Fluid and Electrolyte Imbalances
related to:
lack of sodium and fluid loss through the kidneys, sweat glands, GI tract (for lack of aldosteron)

Outcomes:
  • Adequate urine output (1 cc / kg / hour)
  • Vital signs (within normal limits).
  • Elastic skin turgor.
  • Capillary rise of less than 3 seconds.
  • Mucous membranes moist.
  • Pale skin tone.
  • Ideal weight.

Nursing Intervention for Addison's Disease

1) Monitor TTV, record blood pressure changes in a change in position, the strength of the peripheral pulse.
R /: Hypotension is part of hypovolemia due to lack aldosteron.

2) Measure weight client.
R /: fast weight gain caused by fluid retention and availability of sodium in relation to the treatment of steroids.

3) Study of patients on thirst, fatigue, rapid pulse, capillary filling lengthwise, ugly skin turgor, dry mucous membranes, skin color and the temperature record.
R /: Identifying the influence of hypothermia and volume needs replacement.

4) Check the status of mental and sensory.
R /: Dehydration weight decrease cardiac output, tissue perfusion, especially weight and brain tissue.

5) Auskultasi noisy bowel (peristalsis specific) record and report of nausea, vomiting and diarrhea.
R /: Damage functions intestinal tract, increasing the loss of fluids and electrolytes.

Collaboration:

6. Provide fluids and medications as prescribed.

7. Replace / maintain urinary catheters and NG hose as indicated.
R /: To facilitate accurate measurement of output with both urine and stomach, gastric decompression and provide limiting vomiting.

11) Monitor the results of the laboratory:
a) hematocrit (Ht)
R /: Increased levels of blood hematocrit is an indication of the occurrence of hemoconcentration will return to normal in accordance with the occurrence of dehydration in the body.
b) urea / creatinine
R /: Increased blood urea and creatinine levels is an indication of the level of cell damage due to dehydration / attack sign of heart failure.
c) Sodium
R /: Hyponatremia is an indication of excessive loss through urine katena impaired reabsorption in the renal tubules.
d) Potassium
R /: Decreased levels of aldusteron resulted in a decrease in sodium and water.
READ MORE - Fluid and Electrolyte Imbalances related to Addison's Disease

Nursing Care Plan for Addison's Disease

Addison's Disease was first discovered by Addison in 1885 was caused by a malfunction of the adrenal tissue. The disease is usually autoimmune and adrenal autoantibodies in plasma was found in 75-80% of patients. Addison's disease is very rare. From the results of research in the UK showed a million people just happen only 8 cases. Most cases occur between the ages of 20 to 50 years, but it can occur at any age. This disease can first appear as Addison crisis with fever, abdominal pain, hypotension, collapse, and pigmentation of the skin and mucous membranes due to the very high concentration of ACTH in the circulation.

The disease is associated with a slow decay of the adrenal gland, with a deficiency of cortisol, aldosterone, and adrenal androgens and excess of ACTH and CRH are associated with loss of negative feedback (adhiarta, 1996)

Etiology
Autoimmune (approximately 70-90 cases.
Infections (tuberculosis, histoplasmosis, HIV, Syphilis).
Malignancy (metastases from lung, mammary, colon carcinoma, melanoma, lymphoma).

Clinical manifestations
Symptoms associated with cortisol deficiency
body weak, tired, anorexia, nausea, vomiting, diarrhea, hypoglycemia, mild orthostatic hypertension, hyponatremia, eosinophilia.
Symptoms associated with a deficiency of aldosterone
Orthostatic hypertension, hyperkalemia, hyponatremia
Symptoms associated with androgen deficiency
Losing feathers axilla and pubis.
Symptoms associated with excess ACTH.
Hyperpigmentation of the skin and mucosal surfaces.

Complication
Diabetes mellitus.
Shock.
Lung Cancer.
Sepsis.
Hypoglycemia.
Dehydration.
Circulation collapse.

Physical Examination (Review Of System)
B1: Chest symmetrical, rapid chest movement, absence of respiratory muscle contraction (dyspnoea), there is a movement of the nostrils, resonant, there is the sound crackles, crackles on the state of infection.
B2: ICTUS cordis does not appear, ICTUS cordis palpable on ICS 5-6 clavikula mid line of the left, dim, weak heart sounds, Increased heart rate / pulse at minimal activity.
B3: Dizziness, syncope, trembling, weakness, numbness, disorientation to time, place, space (due to low sodium levels), lethargy, mental fatigue, sensitive to stimuli, anxiety, coma (in a crisis)
B4: diuresis followed by oliguria, changes in the frequency and characteristics of urine.
B5: Mouth and throat: decreased appetite, dry mouth, intestinal bisung ↑, tenderness because there is abdominal cramps.
B6: Decreased muscle tone, fatigue, pain / weakness in the muscles occurs worsening every day), not able to move / work. decrease in strength and range of motion.


Nursing Diagnosis for Addison's Disease

1. Fluid and Electrolyte Imbalances
related to:
lack of sodium and fluid loss through the kidneys, sweat glands, GI tract (for lack of aldosteron)

2. Imbalanced Nutrition Less than Body Requirement
related to:
intake not adekuat (nausea, vomiting, anorexia) glukontikord deficiency.

3. Activity intolerance
relating to:
production decrease metabolism, fluid imbalance of electrolytes and glucose.

4. The Self-concept disturbance
relating to changes in the ability of the function, change the characteristics of the body.

5. Self-care Deficit
relation to muscle weakness.

6. Impaired Urinary Elimination
related to:
disturbance in tubular reabsorption.
READ MORE - Nursing Care Plan for Addison's Disease

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