Nursing Interventions for Pulmonary Tuberculosis - Ineffective Airway Clearance

Nursing Diagnosis :

Ineffective airway clearance related to thick secretions or blood secretions, weakness, poor cough effort, edema, tracheal / pharyngeal.


Goals :

After a given airway hygiene nursing actions effectively, with the result criteria:

• Maintain the patient's airway.
• Removing secretions without help.
• Demonstrate behaviors to improve airway clearance.
• Participate in treatment programs as needed.
• Identify potential complications and appropriate action.

Nursing Interventions - Ineffective Airway Clearance 

• Review of respiratory functions: breathing, pace, rhythm, depth and use of accessory muscles.
• Note the ability to issue secret or cough effectively, record the character, amount of sputum, presence of hemoptysis.
• Give the patient or the semi-Fowler position, help / teach effective coughing and deep breathing exercises.
• Clean secretions from the mouth and trachea, suction if necessary.
• Maintain a fluid intake of at least 2500 ml / day unless contraindicated.
• Moisten the air / oxygen inspiration.

Rational:

• Decrease in breath sounds indicative of atelectasis, crackles indication of accumulation of secret / inability to clear the airway so that the accessory muscle use and increased work of breathing.
• Expenditure is difficult when thick secretions, sputum, bleeding from bronchial lung damage or injury which requires evaluation / intervention information.
• Increase lung expansion, maximum ventilation opening area and increase the movement of secretions, atelectasis to be easily removed.
• Prevent obstruction / aspiration. Suction done when patients are unable to remove secretions.
• Help thin the secret so easily removed.
• Prevent drying of mucous membranes.