Nursing Care Plan for Bronchiectasis

Definition

Bronchiectasis means a dilation that can not be recovered again from bronchial caused by recurrent episodes of pneumonitis and elongated, foreign body aspiration, or mass (ie. Neoplasm) that inhibit the bronchial lumen obstruction. (Hudak & Gallo, 1997).



Classification
Based on bronchography and pathology, bronchiectasis can be divided into three, namely:
  • Cylindrical bronchiectasis.
  • Fusiform bronchiectasis.
  • Saccular or cystic bronchiectasis.


Etiology
  • Infection.
  • Hereditary disorder or congenital abnormalities.
  • Mechanical factors that facilitate the onset of infection.
  • Often patients have a history of pneumonia as a complication of measles, whooping cough, or other infectious diseases in childhood.



Signs and symptoms
  • Chronic cough with sputum that is a lot, especially in the morning, after sleeping.
  • Cough with sputum accompanying cold cough for 1-2 weeks or no symptoms at all (mild Bronchiectasis)
  • Persistent cough with sputum that is much less than 200-300 cc, accompanied by fever, no appetite, weight loss, anemia, pleural pain, and weak body sometimes shortness of breath and cyanosis, sputum often contain blood spots, and coughing up blood.
  • Found finger-clubbing in 30-50% of cases.

Nursing Care Plan for Bronchiectasis



Nursing Diagnosis for Bronchiectasis



Ineffective airway clearance related to the increased production of secretions, thick secretions.

Goal: retain patent airway with breath sounds clean / clear.

Expected outcomes:
Shows the behavior to improve airway clearance (effective cough, and issued a secret.

Interventions:
1. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.
R /: Tachipneu common to some degree can be found at the reception or immersion stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.

2. Auscultation of breath sounds and record their breath sounds
R /: The degree of bronchospasm occurs with airway obstruction and can / do not manifested their breath sounds.

3. Assess the patient to a comfortable position, high headboard and sat at the back of the bed.
R /: Elevation of the head of the bed easier for respiratory function by using gravity. And make it easier to breathe and helps reduce muscle weakness and can be as a tool chest expansion.

4. Help abdominal breathing exercises or lips.
R / To cope with and control dyspnea and lower air entrapment.

5. Observe the characteristic cough and aid measures for the effectiveness of efforts to cough.
R / Knowing the effectiveness of cough.

6. Enter the liquid till 3000ml / day according to the tolerance of the heart, as well as provide a warm and fluid intake between as a meal replacement.
R /: Hydration helps to lower the viscosity of the secret, warm facilitate discharge can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.

7. Give the drug as indicated.
R /: Speed up the process of healing.