Nursing Care Plan

Nursing Care of Patients with Respiratory System Disorders

Respiratory System Disorders

A. Medical History

Medical history that were examined include current data and past issues. The nurse examines the client or family and focus on the clinical manifestations of the main complaints, events that make the current situation, past treatment history, family history and psychosocial history.

Medical history starting from the biography of the client, in which aspects of the biography of a very close relationship with oxygenation disorders include age, sex, occupation (especially those related to working conditions) and shelter. State of residence includes living conditions and whether the client lives alone or with others which will be useful for discharge planning ("Discharge Planning").

  1. The main complaint

    The main complaint will determine the priority interventions and assess the client's knowledge of his condition at this time. The main complaint that usually appears on the client's need for oxygen and carbon dioxide interference include: cough, increased sputum production, dyspnea, hemoptysis, wheezing, chest pain and Stridor.

    • Cough
      Cough is the main symptom in clients with respiratory system diseases. Ask how long the client cough (eg 1 week, 3 months). Ask also how it was incurred by a specific time (eg at night, when I wake up) or its relationship with physical activity. Determine whether the cough is productive or non productive, congestion, dry.

    • Increased sputum production
      Sputum is a substance that comes out along with a cough or throat clearance. Tracheobronchial tree normally produces about 3 ounces of mucus a day as part of normal cleaning mechanism. But the production of sputum due to coughing is not normal. Ask and record the color, consistency, odor and amount of sputum because these things can indicate a state of pathological processes. If infections develop sputum, can be yellow or green, Sputum may be clear, white or gray. In case of pulmonary edema will be colored pink sputum, and blood contains large amounts.

    • Dyspnea
      Dyspnea is a perception of difficulty in breathing / shortness of breath and a subjective feeling of the client. Nurses learn about the client's ability to perform activities. Instances when the client is running if she experienced dyspnea?. also examine the possibility of paroxysmal nocturnal dyspnea and orthopnea, which is associated with chronic lung disease and heart failure left.

    • Hemoptysis
      Hemoptysis is blood coming out of the mouth coughed. Nurses assess whether the blood is coming from the lungs, nose or stomach bleeding. Blood from the lungs is usually bright red because of blood in the lung are stimulated by a reflex cough immediately. Diseases that cause hemoptysis include: Chronic bronchitis, bronchiectasis, pulmonary tuberculosis, cystic fibrosis, Upper airway necrotizing granulomas, pulmonary embolism, pneumonia, lung cancer and lung abscess.

    • Chest Pain
      Chest pain may be associated with heart and lung problems. Complete picture of chest pain can help nurses to differentiate pleural pain, musculoskeletal, cardiac and gastrointestinal. The lungs do not have the nerves that are sensitive to pain, but the ribs, muscles, parietal pleura and tracheobronchial tree have it. Due to the subjective feeling of pure pain, nurses must analyze the pain associated with painful problems that arise.

  2. Past Medical History

    The nurse asks about the client's history of respiratory disease. In general, the nurse asked about:

    • History of smoking: cigarette smoking is an important cause of lung cancer, emphysema and chronic bronchitis. All the circumstances it is very rarely happen to non-smokers. Anamnesis should include the:
      • Age of onset of smoking on a regular basis.
      • The average number of cigarettes smoked per day.
      • Removing age smoking.
    • Treatment of current and past
    • Allergy
    • Place of residence

    • Family Health History

      Purpose to ask family and social history of lung disease patients are at least three, namely:
      1) certain infectious diseases: tuberculosis, especially, is transmitted through one individual to another, so by asking for a history of contact with infected people can know the source of transmission.
      2) allergic disorders, such as bronchial asthma, suggesting a predisposition certain breeds, and also the asthma attacks may be triggered by the conflict of family or close acquaintances.
      3) Patients with chronic bronchitis may be living in areas of high air pollution. But air pollution does not cause chronic bronchitis, only aggravate the disease.
    2. Review System (Head to Toe)
    • Inspection

      1. Examination of the chest starts from the posterior thorax, the client in a seated position.
      2. Chest observed by comparing one side to another.
      3. Actions done from the top (apex) to bottom.
      4. Inspection of the thorax poterior skin color and condition, scars, lesions, masses, spinal problems such as kyphosis, scoliosis and lordosis.
      5. Record the number, rhythm, depth of breathing, chest movement and symmetry.
      6. Observation of the respiratory type, such as: nasal breathing or diaphragmatic breathing, and the use of auxiliary respiratory muscles.
      7. When observing respiration, record the duration of the phase of inspiration (I) and expiratory phase (E). ratio in this phase of the normal 1: 2. Prolonged expiratory phase showed the presence of airway obstruction and is often found on client Chronic Airflow Limitation (CAL) / COPD
      8. Assess and compare the configuration of the chest anteroposterior diameter (AP) and lateral diameter / tranversal (T). This ratio normally ranges from 1: 2 to 5: 7, depending on the client's body fluids.
      9. Abnormalities in the form of the chest:
        • Barrel Chest
          Barrel chest describes a rounded, bulging, almost barrel-like appearance of the chest that occurs as a result of long-term overinflation of the lungs. Because the lungs are overinflated with air, the rib cage stays partially expanded, giving the characteristic appearance of a barrel chest.
          Barrel chest can be due to a variety of reasons, including osteoarthritis and aging, but is also a common finding in the later stages of emphysema. Barrel chest is quite obvious, and can be detected by your healthcare provider during a physical examination.

        • Funnel chest (Pectus Excavatum)
          Depression of the breast bone - sunken chest appearance. The condition is usually a congenital deformity but may occur in association with conditions such as rickets, Marfan syndrome and Poland syndrome. Severe cases may result in breathing problems or may affect heart function.

        • Pigeon Chest (pectus carinatum)
          Pectus carinatum also called pigeon chest, is a deformity of the chest characterized by a protrusion of the sternum and ribs. It is the opposite of pectus excavatum.

        • Kyphoscoliosis
          Kyphoscoliosis describes an abnormal curvature of the spine in both a coronal and sagittal plane. It is a combination of kyphosis and scoliosis. Kyphoscoliosis is a musculoskeletal disorder causing chronic underventilation of the lungs and may be one of the major causes of pulmonary hypertension.
          Kyphosis also called roundback or Kelso's hunchback, is a condition of over-curvature of the thoracic vertebrae (upper back). It can be either the result of degenerative diseases (such as arthritis), developmental problems (the most common example being Scheuermann's disease), osteoporosis with compression fractures of the vertebrae, or trauma.
          Scoliosis: is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis may look more like an "S" or a "C", rather than a straight line.
      10. Observation of chest movement symmetry. Movement disorders or inadequate chest expansion indicated in the lung or pleural disease.
      11. Observation of abnormal retraction of the intercostal spaces during inspiration, which may indicate airway obstruction.

    • Palpation

      Conducted to assess the symmetry and observe chest movement abnormalities, identify the state of the skin and knowing vocals / premitus tactile (vibration).
      Palpation of the thorax to find out when inspections terkaji abnormality such as masses, lesions, swelling.
      Assess the softness of the skin, especially if a client complains of pain.
      Vocal premitus: chest wall vibration generated when speaking.

    • Percussion

      Nurses to assess the resonance pulmonary percussion, organ and development around it (excursion) of the diaphragm.
      • Resonant : normal: resonant, low tones. Generated in normal lung tissue.
      • Dullness: normal: upper parts produced in the heart or lungs.
      • Tympany: normal: the musical, produced in the stomach is filled with air.
    • Percussion sounds Abnormal:
      • Hyperresonant: Louder sound heard over lungs upon percussion. Longer sound heard over lungs upon percussion. Higher pitched sound heard over lungs upon percussion.
      • Flatness: very dullness and therefore a higher tone. Percussion can be heard on the thigh area, which contains the whole area network.

    • Auscultation

      Is a very meaningful assessment, including listening to breath sounds normal, additional sound (abnormal), and sound.
      Normal breath sounds from the vibrations produced when the air through the airway from the larynx to the alveoli, with the clear.
    3. Psychosoial Assessment

    The review of aspects of the habits of the clients that significantly affect the function of respiration. Some respiratory conditions resulting from stress.

    Chronic respiratory disease may cause changes in family roles and relationships with others, social isolation, financial problems, work or disability.

    By discussing coping mechanisms, the nurse can assess the client's reaction to the problem of psychosocial stress and find a way out.


    NURSING DIAGNOSIS

    Nursing diagnosis related to disorders of oxygenation that includes ventilation, diffusion and transport, according to the classification of NANDA (2005) and the development of writers, among others:

    1. Ineffective airway clearance (Damage to the physiology of ventilation)

    Is a condition where an individual is unable to cough effectively.

    2. Impaireed gas exchange (damage to the physiology of diffusion)

    Condition in which the decline in gas intake between alveoli and the vascular system.

    3. Ineffective breathing pattern (damage to the physiology of transport)

    A condition is inadequate ventilation related to changes in breathing pattern. Hiperpnea or hyperventilation will cause a decrease in PCO2...

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