Chronic Bronchitis Nursing Care Plan
Ineffective Airway Clearance
Assessment
Patient may manifest
- Wheezes/crackles on auscultation on the BLF
- Subcostal retraction
- Nasal flaring
- Presence of non-productive cough
- Increase RR above normal range
Nursing Diagnosis
- Ineffective Airway Clearance
Outcomes
- Patient will demonstrate effective clearing of secretions.
- Patient will maintain effective airway clearance.
Nursing Interventions
- Position head midline with flexion on appropriate for age/condition
- Rationale: To gain or maintain open airway
- Elevate HOB
- Rationale: To decrease pressure on the diaphragm and enhancing drainage
- Observe S/Sx of infections
- Rationale: To identify infectious process
- Auscultate breath sounds & assess air mov’t
- Rationale: To ascertain status & note progress
- Instruct the patient to increase fluid intake
- Rationale: To help to liquefy secretions.
- Demonstrate effective coughing and deep-breathing techniques.
- Rationale: To maximize effort
- Keep back dry
- Rationale: To prevent further complications
- Turn the patient q 2 hours
- Rationale: To prevent possible aspirations
- Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage.
- Rationale: These techniques will prevent possible aspirations and prevent any untoward complications
- Administer bronchodilators if prescribed.
- Rationale: More aggressive measures to maintain airway patency.
Ineffective Breathing Pattern
Assessment
Patient may manifest
- Wheezes/crackles on auscultation on the BLF
- Subcostal retraction
- Nasal flaring
- Presence of non-productive cough
- Increase RR above normal range
Nursing Diagnosis
- Ineffective Breathing Pattern RT Retained Secretions
Outcomes
- Patient will improve breathing pattern.
- Patient will maintain a respiratory rate within normal limits.
Nursing Interventions
- Place patient in semi-fowlers position
- Rationale: To have a maximum lung expansion
- Increase fluid intake as applicable
- Rationale: To liquefy secretions
- Keep patient back dry
- Rationale: To avoid stasis of secretions and avoid further complication
- Change position every 2 hours
- Rationale: To facilitate secretion mov’t and drainage
- Perform CPT
- Rationale: To loosen secretion
- Place a pillow when the client is sleeping
- Rationale: To provide adequate lung expansion while sleeping.
- Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate
- Rationale: To promote physiological ease of maximal inspiration
- Maintain a patent airway, suctioning of secretions may be done as ordered
- Rationale: To remove secretions that obstructs the airway
- Provide respiratory support. Oxygen inhalation is provided per doctor’s order
- Rationale: To aid in relieving patient from dyspnea
- Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired.
- Rationale: To promote deeper respirations and cough
Impaired Gas Exchange
Assessment
Patient may manifest
- Appearance of bluish extremities when in cough (cyanosis), lips
- Lethargy
- Restlessness
- Hypercapnea
- Hypoxemia
- Abnormal rate, rhythm, depth of breathing
- Diaphoresis
Nursing Diagnosis
- Impaired Gas Exchange RT Altered Oxygen Balance
Outcomes
- Patient will improve ventilation and adequate oxygenation of tissues
- Patient will minimize or totally be free of symptoms of respiratory distress.
Nursing Interventions
- Monitor level of consciousness or mental status
- Rationale: Restlessness,anxiety, confusion, somnolence are common manifestation of hypoxia and hypoxemia.
- Assist the client into the High-Fowlers position
- Rationale: The upright position allows full lung excursion and enhances air exchange
- Increase patient’s fluid intake
- Rationale: To help liquefy secretions
- Encourage expectoration
- Rationale: To eliminate thick, tenacious, copious secretions which contribute for the impairment of gas exchange.
- Encourage frequent position changes
- Rationale: To promote drainage of secretions
- Encourage adequate rest & limit activities to within client tolerance
- Rationale: Helps limit oxygen needs/consumption
- Promote calm/restful environments
- Rationale: To correct/improve existing deficiencies
- Administer supplemental oxygen judiciously as indicated
- Rationale: May correct or prevent worsening of hypoxia.
- Administer meds as indicated such as bronchodilators
- Rationale: To treat the underlying condition
Sleep Pattern Disturbance
Assessment
Patient may manifest
- Irritability
- Restlessness
- Lethargy
- Changes in posture
- Difficulty of breathing which worsens at night
Nursing Diagnosis
- Sleep Pattern Disturbance RT Difficulty of Breathing
Outcomes
- Patient will identify individually appropriate interventions to promote sleep.
- Patient will be able to report improvements in sleep/rest pattern.
Nursing Interventions
- Monitor level of consciousness or mental status
- Rationale: Restlessness, anxiety,confusion, somnolence are common manifestation of hypoxia and hypoxemia.
- Promote comfort measures such as back rub and change in position as necessary
- Rationale: To provide non pharmacologic management
- Observe provision of emotional support
- Rationale: Lack of knowledge and problems, relationships may create tension. Interfering with sleep routines based on adult schedules may not meet child’s needs.
- Provide quiet environment.
- Rationale: To promote an environment conducive to sleep.
- Increase patient’s fluid intake
- Rationale: To help liquefy secretions
- Encourage expectoration
- Rationale: To eliminate thick, tenacious, copious secretions which contribute for the DOB
- Limit the fluid intake in evening if nocturia is a problem
- Rationale: To reduce need for nighttime elimination
- Obtain feedback from SO regarding usual bedtime, rituals/routines
- Rationale: To determine usual sleep patterns & provide comparative baseline
- Provide safety for patient sleep time safety
- Rationale: To promote comfort/safety
- Recommend mid morning nap if one required
- Rationale: Napping esp. in the afternoon can disrupt normal sleep pattern
- Administer pain medication as ordered.
- Rationale: To relieve discomfort and take maximum advantage of sedative effect
Risk for Spread of Infection
Assessment
Patient may manifest
- Body temperature above normal range
- Dehydration
- Increase WBC count
- Presence of increase mucus production
Nursing Diagnosis
- Risk for Spread of Infection RT Stasis of Secretions & Decreased Ciliary Action
Outcomes
- Patient will identify interventions to prevent and/or reduce the risk of infection
- Patient will have minimize or totally be free from the risk of infection.
Nursing Interventions
- Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake
- Rationale: These activities promote mobilization and expectoration of secretions to reduce the risk of developing pulmonary infection.
- Turn the patient q 2 hours
- Rationale: To facilitate secretion mov’t and drainage
- Encourage increase fluid intake
- Rationale: To liquefy secretions
- Stress the importance of handwashing to SO’s
- Rationale: Handwashing is the primary defense against the spread of infection
- Teach the SO’s how to care for and clean respiratory equipment
- Rationale: Water in respiratory equipment is a common source of bacterial growth
- Teach the SO’s the manifestations of pulmonary infections (change in color of sputum, fever, chills) , self-care and when to call the physician
- Rationale: Early recognition of manifestations can lead to a rapid diagnosis.
- Recommend rinsing mouth with water
- Rationale: To prevent risk of oral candidiasis.
- Administer antimicrobial such as cefuroxime as indicated.
- Rationale: Given prophylactically to reduce any possible complications
Other Possible Nursing Care Plans
- High risk for suffocation
- High risk for aspiration
- Anxiety RT acute breathing difficulties
- Activity Intolerance RT inadequate oxygenation
- Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea (for emphysema)
