Nursing Care Plan for ARDS
Nursing Diagnosis : Ineffective airway clearance
related to:
- Loss of function of cilia airway (hypoperfusion).
- Increasing the number / viscosity of pulmonary secretions.
- Increased retention of the airway (interstitial edema).
- Reports dyspnea.
- Change the depth / respiratory rate, use of accessory muscles to breathe.
- Cough (effective or ineffective) with / without sputum production. Anxiety / restlessness.
- Stating / show loss of dyspnea.
- Maintain a patent airway with breath sounds clean / no crackles.
- Issued a secret without difficulty.
- Show behavior to improve / maintain airway clearance.
Intervention:
Independent:
- Note the change of effort and breathing patterns.
- Observations decrease in chest wall expansion and presence / increase fremitus.
- Note the characteristic sound of the breath.
- Note the characteristic cough (eg, cough settled, effective / ineffective) is also sputum production and characteristics.
- Maintain the position of the body / head right and use the tools of the airway as needed.
- Help with coughing / deep breath, reposition and exploitation as indicated.
Collaboration:
Give moist oxygen, IV fluids, give proper humidity of the room.
- Give aerosol therapy, ultrasonic nebulizer.
- Help with / provide chest physiotherapy, postural drainage example: chest percussion / vibration according to indications.
- Give bronchodilators.
- Keep an eye for adverse side effects of the drug, eg tachycardia, hypertension, tremors, insomnia.
Rational:
Independent:
- Intercostal muscle use / abdominal and nasal dilation showed increased respiratory effort.
- Chest expansion is limited or not the same with respect to fluid accumulation, edema, and secret.
- Consolidation of lung and fluid replenishment can increase fremitus.
- Breath sounds indicate the flow of air through the tracheobronchial tree and is influenced by the presence of fluid, mucus, or other airflow obstruction. Wheezing can constitute evidence in connection with the narrowing of the airway edema. Crackles may be clear without coughing and showing the collection of mucus in the airways.
- Cough characteristics may change depending on the cause / etiology of respiratory failure. Sputum, when there may be many, thick, bloody, or purulent.
- Facilitate maintain a patent airway or if the patient's airway is affected ie., Disturbance of consciousness, sedation and maxillofacial trauma.
- The collection of secretions interfere with ventilation or pulmonary edema and if the patient is not intubated, increase oral fluid intake can dilute / increase spending.
Collaboration:
- Humidity will remove and mobilize secretions and increase oxygen transport.
- Treatment is made to deliver oxygen / bronchodilation / humidity firmly on the alveoli and to mobilize secret.
- Improve drainage / elimination of pulmonary secretions into the central bronchi, which can be more readily coughed or sucked out.
- Improve the efficiency of use of the breathing muscles and help the expansion of the alveoli.
- Drug given to relieve bronchospasm, lowering the viscosity of secretions, improve ventilation and easier disposal secret.
- Require a change in dose / drug options.