Nursing Care Plan for Bronchiectasis
Bronchiectasis is a chronic dilatation of the bronchi and bronchioles that may be caused by various conditions, including lung infections and bronchial obstruction; foreign body aspiration, vomit, and objects from the upper respiratory tract; and the pressure due to a tumor, blood vessels dilated and enlarged lymph nodes (Brunner & Suddart, 2002).
According Suyono (2001) etiology of bronchiectasis are:
1. Infection
Bronchiectasis often occur after a child suffering from pneumonia who frequently relapse and long lasting. Pneumonia is generally a pertussis or influenza complications suffered during the child, pulmonary tuberculosis, and so on.
2. Abnormalities hereditary or congenital abnormalities
In this case bronchiectasis occurs in the womb. Genetic factors or growth factors and fetal development plays an important role. Usually has the characteristics on almost all branches of the bronchi in the lungs one or two. Usually accompanied by other congenital diseases.
3. Bronchial obstruction
Obstruction is meant as a corpus alienum, bronchial carcinoma and other external pressure against the bronchi.
Pathophysiology
According to Brunner & Suddarth (2002) pathophysiology of bronchiectasis starting from infections that damage the bronchial wall, causing loss of supporting structure and produce thick sputum that can eventually clog the bronchi. Bronchial walls become stretched permanently as a result of severe coughing, infection extends to peri bronchial, so that in the case of secular bronchiectasis, each tube is actually dilated pulmonary abscess, which exudates to flow freely through the bronchi. Bronchiectasis is usually local, attacking lung lobe segment. Lower lobe most often affected.
Retention secretion and obstruction resulting eventually cause obstruction distal side alveoli collapse (atelectasis). Due to scarring or fibrosis replaces lung tissue inflammatory reaction that function. At the time the patient suffered respiratory insufficiency with a decrease in vital capacity, decreased ventilation, and an increase in the ratio of residual volume to total lung capacity. There is damage to the gas mixture in the inspiration (ventilation-perfusion mismatch) and hypoxemia.
According Suyono (2001) the signs and symptoms of bronchiectasis as follows:
1. Cough
Hemoptysis is characterized, among others; ongoing chronic productive cough, sputum amount varies, generally polynomial in the morning after there is a sleeping position or wake up from sleep. Sputum consists of three layers:
Caused by necrosis or destruction of the bronchial mucosa blood vessels (rupture) and the resulting bleeding.
3. Shortness of breath (dyspnea)
Onset of shortness of breath depends on the extent of bronchiectasis, sometimes causing wheezing sound due to bronchial obstruction.
4. Recurrent fever
Bronchiectasis is a chronic disease, often experience recurrent infection of the bronchi and the lungs, often resulting in fever (recurrent fever).
5. Physical Abnormalities
Nursing Care Plan for Bronchiectasis
Nursing Diagnosis : Ineffective airway clearance related to the increased production of secretions, thick secretions.
Goal: Maintain a patent airway with breath sounds clean / clear.
Expected outcomes: Demonstrate behaviors to improve airway clearance (effective cough, and issued a secret.)
Intervention:
1. Auscultation of breath sounds and record their breath sounds.
R /: The degree of bronchospasm occurs with airway obstruction and can / not characterized by the presence of breath sounds.
2. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.
R /: Tacipneu common to some degree can be found at the reception or during stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.
3. Assess the patient to a comfortable position, Height head of the bed and sat on the back of the bed.
R /: Elevation headboard ease respiratory function by means of gravity. And make it easier to breathe, and help decrease muscle weakness and can be as a tool chest expansion.
4. Help abdominal breathing exercises or lips.
R / To cope with and control of dyspnea and lower air entrapment.
5. Observe the characteristic cough and aid effectiveness action to cough effort.
R /: Knowing the effectiveness of cough.
6. Increase fluid intake till 3000ml / day as tolerated heart and give a warm and fluid intake between as a meal replacement.
R /: Hydration helps to lower the viscosity of secretions, simplify expenditure warm fluids can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.
7. Give the drug as indicated.
R /: Speed up the healing process.
According Suyono (2001) etiology of bronchiectasis are:
1. Infection
Bronchiectasis often occur after a child suffering from pneumonia who frequently relapse and long lasting. Pneumonia is generally a pertussis or influenza complications suffered during the child, pulmonary tuberculosis, and so on.
2. Abnormalities hereditary or congenital abnormalities
In this case bronchiectasis occurs in the womb. Genetic factors or growth factors and fetal development plays an important role. Usually has the characteristics on almost all branches of the bronchi in the lungs one or two. Usually accompanied by other congenital diseases.
3. Bronchial obstruction
Obstruction is meant as a corpus alienum, bronchial carcinoma and other external pressure against the bronchi.
Pathophysiology
According to Brunner & Suddarth (2002) pathophysiology of bronchiectasis starting from infections that damage the bronchial wall, causing loss of supporting structure and produce thick sputum that can eventually clog the bronchi. Bronchial walls become stretched permanently as a result of severe coughing, infection extends to peri bronchial, so that in the case of secular bronchiectasis, each tube is actually dilated pulmonary abscess, which exudates to flow freely through the bronchi. Bronchiectasis is usually local, attacking lung lobe segment. Lower lobe most often affected.
Retention secretion and obstruction resulting eventually cause obstruction distal side alveoli collapse (atelectasis). Due to scarring or fibrosis replaces lung tissue inflammatory reaction that function. At the time the patient suffered respiratory insufficiency with a decrease in vital capacity, decreased ventilation, and an increase in the ratio of residual volume to total lung capacity. There is damage to the gas mixture in the inspiration (ventilation-perfusion mismatch) and hypoxemia.
According Suyono (2001) the signs and symptoms of bronchiectasis as follows:
1. Cough
Hemoptysis is characterized, among others; ongoing chronic productive cough, sputum amount varies, generally polynomial in the morning after there is a sleeping position or wake up from sleep. Sputum consists of three layers:
- The top layer; rather cloudy, consisting of mucus.
- The middle layer; clearly consists of saliva.
- The bottom layer; turbid, consisting of pus and tissue necrosis of bronchial damaged.
Caused by necrosis or destruction of the bronchial mucosa blood vessels (rupture) and the resulting bleeding.
3. Shortness of breath (dyspnea)
Onset of shortness of breath depends on the extent of bronchiectasis, sometimes causing wheezing sound due to bronchial obstruction.
4. Recurrent fever
Bronchiectasis is a chronic disease, often experience recurrent infection of the bronchi and the lungs, often resulting in fever (recurrent fever).
5. Physical Abnormalities
- Cyanosis
- Clubbing
- Bronchi wet
- Whezing
Nursing Care Plan for Bronchiectasis
Nursing Diagnosis : Ineffective airway clearance related to the increased production of secretions, thick secretions.
Goal: Maintain a patent airway with breath sounds clean / clear.
Expected outcomes: Demonstrate behaviors to improve airway clearance (effective cough, and issued a secret.)
Intervention:
1. Auscultation of breath sounds and record their breath sounds.
R /: The degree of bronchospasm occurs with airway obstruction and can / not characterized by the presence of breath sounds.
2. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.
R /: Tacipneu common to some degree can be found at the reception or during stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.
3. Assess the patient to a comfortable position, Height head of the bed and sat on the back of the bed.
R /: Elevation headboard ease respiratory function by means of gravity. And make it easier to breathe, and help decrease muscle weakness and can be as a tool chest expansion.
4. Help abdominal breathing exercises or lips.
R / To cope with and control of dyspnea and lower air entrapment.
5. Observe the characteristic cough and aid effectiveness action to cough effort.
R /: Knowing the effectiveness of cough.
6. Increase fluid intake till 3000ml / day as tolerated heart and give a warm and fluid intake between as a meal replacement.
R /: Hydration helps to lower the viscosity of secretions, simplify expenditure warm fluids can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.
7. Give the drug as indicated.
R /: Speed up the healing process.
