Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway

RELATED FACTORS Environmental Smoking; secondhand smoke; smoke inhalation Obstructed airway Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway Physiological Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls Neuromuscular dysfunction Infection The Nursing Clinics of North America (Volume 22, #1) Cardiac Monitoring & Ineffective Breathing Patterns and Airway Clearance DEFINING CHARACTERISTICS Subjective Dyspnea Objective Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes] Cough, ineffective/absent; excessive sputum Changes in respiratory rate and rhythm Difficulty vocalizing Wide-eyed; restlessness Orthopnea Cyanosis

Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic fibrosis, neuromuscular diseases, inhalation injuries

Client Will (Include Specific Time Frame) Maintain airway patency. Expectorate/clear secretions readily. Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms). Verbalize understanding of cause(s) and therapeutic management regimen. Demonstrate behaviors to improve or maintain clear airway. Identify potential complications and how to initiate appropriate preventive or corrective actions.

NURSING PRIORITY NO.1 To maintain adequate, patent airway: Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways. Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions. Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).

Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea. Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway. Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated. Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs. Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs. Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors. Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway. Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.

NURSING PRIORITY NO.2 To mobilize secretions: Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort. Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.) Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.

Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments. Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort. Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions. Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain). Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions. Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.) Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.

NURSING PRIORITY NO.3 To assess changes, note complications: Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways. Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress. Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.

Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.) Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client s decision making about medication regimen and response to any given medication. Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention. Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.

NURSING PRIORITY NO.4 To promote wellness (Teaching/Discharge Considerations): Assess client s/caregiver s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs. Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount. Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection. Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called huffing ] or respiratory muscle strength training, chest percussion), if indicated. Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia. Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).

Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways. Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function. Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association). Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)

DOCUMENTATION FOCUS Assessment/Reassessment Related factors for individual client. Breath sounds, presence/character of secretions, use of accessory muscles for breathing. Character of cough/sputum. Planning Plan of care and who is involved in planning. Teaching plan. Implementation/Evaluation Client s response to interventions/teaching and actions performed. Attainment/progress toward desired outcome(s). Modifications to plan of care. Discharge Planning Long-term needs and who is responsible for actions to be taken. Specific referrals made. Posted in: nursing diagnoses

M.I

In Myocardial Infarction, inadequate coronary blood flow rapidly results in myocardial ischemia in the affected area. The location and extent of the infarct determine the effects on cardiac function. Ischemia depresses cardiac function and triggers autonomic nervous systemresponses that exacerbate the imbalance between myocardial oxygen supply and demand. Persistent ischemia results in tissue necrosis and scar tissue formation, with permanent loss of myocardial contractility in the affected area. Cardiogenic shock may develop because of inadequate CO from decreased myocardial contractility and pumping capacity.

Pathophysiology
The spectrum of myocardial injury depends not only on the intensity of impaired myocardial perfusion but also on the duration and the level of metabolic demand at the time of the event. The damage in the myocardium is essentially the result of a tissue response that includes apoptosis (cell death) and inflammatory changes. Therefore, the hearts of patients who suddenly die from an acute coronary event may show little or no evidence of damage response to the myocardium at autopsy. The typical myocardial infarction initially manifests as coagulation necrosis that is ultimately followed by myocardial fibrosis. Contraction-band necrosis is also seen in many patients with ischemia. This is followed by reperfusion, or it is accompanied by massive adrenergic stimulation, often with concomitant myocytolysis. The left coronary artery system covers more territory than does the right system; therefore, a myocardial infarction in this system is most likely to produce extensive injury, with impairment of function, pulmonary congestion, and low output. Occlusion of the left coronary artery may also cause a left anterior hemiblock or a left posterosuperior hemiblock conduction abnormality; these effects are evidenced by a change of frontal axis on the electrocardiogram (ECG). (See Electrocardiogram.) Inferior-wall myocardial infarction and right ventricular myocardial infarction In severe cases of acute inferior-wall myocardial infarction with RV involvement, the forward delivery of blood from the RV to the LV may be insufficient to fill the LV, resulting in low blood pressure even if the LV is intact. (See Physical Examination.) Chemoreceptor activation in the myocardium actuates vagal (parasympathetic) efferent discharge, known as the Bezold-Jarisch reflex, which causes bradycardia and vessel dilation that may further lower blood pressure. Adenosine may accumulate in the infarct zone secondary to a local inhibition of adenosine deaminase, for which aminophylline may act pharmacologically as an antagonist. The hemodynamic changes resemble many of those seen with pericardial constriction or tamponade. Patients with this condition respond well to an infusion of normal sodium chloride solution. Improvement with such infusion compensates for failure of the pumping action of the RV; it reduces vagal tone, and it deactivates the pressure sensors that were sending a hormonal signal to the kidneys to retain salt.

Pneumonia
DEFINITION: An inflammation of the lungs caused by an infection.

RELATED DIAGNOSTIC TESTS: Crackles are heard when listening to the chest with a stethoscope (auscultation). Tests include: chest Xray, sputum gram stain, CBC,arterial blood gases. This disease may also alter the results of the following tests: thoracic CT, routine sputum culture, pulmonary ventilation/perfusion scan, pleural fluid culture, lung needle biopsy .

ETIOLOGY: Pneumonia is a very common, serious illness and affects about 1 out of 100 people each year. It is caused by many different organisms and can range in seriousness from mild to life-threatening illness. There are different categories of pneumonia.

MEDICAL MANAGEMENT: The goal of treatment is to cure the infection with antibiotics. If the pneumonia is caused by a virus, antibiotics will not be effective. Supportive therapy includes oxygen and respiratory treatments to remove secretions.

PATHOPHYSIOLOGY:

NURSING MANAGEMENT:

 There are different categories of pneumonia. Two of these types are hospital-acquired and community-acquired. Common types of community-acquired pneumonia are pneumococcal pneumonia and Mycoplasma pneumonia. In some people, particularly the elderly and those who are debilitated, pneumonia may follow influenza. Hospitalacquired pneumoniatends to be more serious because defense mechanisms against infection are often impaired. Some of the specific pneumonia-related disorders include: aspiration pneumonia, pneumonia in immunocompromised host and viral pneumonia 

Pt will need to have breath sounds monitored q 4r to determine if pneumonia is progressing. O2 sats should be done regularly ( at least q4rduring acute phase) to make sure that patient is getting adequate perfusion. Make sure to give all scheduled antibiotics on schedule so that therapeutic ranges are maintained. Any s/s of infection must be monitored and reported to MD.

 

SIGNS & SYMPTOMS: Cough (with mucus-like, greenish, or pus-like sputum chills with shaking ), fever, easy fatigue, chest pain (sharp or stabbing increased by deep breathing or increased by coughing), headache, loss of appetite, nausea and vomiting, general discomfort, uneasiness, or ill feeling (malaise), joint stiffness (rare), muscular stiffness (rare), rales Additional symptoms that may be associated with this disease: shortness of breath, clammy skin, nasal flaring, coughing up blood, tacypnea, apnea,anxiety, stress, and tension, abdominal pain .

HEALTH DEVIATION SELF-CARE REQUISITES:  Pt will need to continue on scheduled antibiotics after discharge. Teaching may be necessary to inform patient of therapeutic ranges and need to take all of meds, even if they are feeling better. Pt will need to get a PneumonoVax (if does not all ready have0 to help prevent future outbreaks of pneumonia. Pt will need to be taught S/S of infection and when to report to MD.