Nanda - Nursing Care Plan

Hyperthermia and Ineffective Airway Clearance related to Bronchitis

Nursing Diagnosis and Interventions for Bronchitis:

1. Ineffective airway clearance related to increased production of secretions.

Goal: The client does not feel shortness of breath and no sputum.

Expected outcomes:
  • Maintain a patent airway with breath sounds clean or clear.
  • Shows behavior to improve airway clearance, for example: an effective cough.
Interventions:
  • Assess the respiratory function, breath sounds, the speed of the rhythm.
  • Assess a comfortable position for a client.
  • Suggest to cough effectively.
  • Collaboration: Provision mukolitik, Give the drug as an indication.
Rationale:
  • Assist the breathing pattern changes.
  • Breathing can facilitate the circulation in the body.
  • Cough teach effectively so patients independently.
  • To lower airway spasm.
  • Lowering the mucosal edema and smooth muscle spasm.

2. Hyperthermia related to the inflammatory process.

Goal: The client can reach the normal temperature.

Expected outcomes:
  • Normal body temperature (36.5 to 37.5 0C-0C)
Interventions:
  • Give a warm compress or cold pack in accordance with the client's approval.
  • Encourage clients to use clothing that is thin and absorbs perspiration.
  • Dressing damp or wet with sweat that much.
  • Give a thin blanket.
  • Collaboration: Give antipyretics.
Rationale:
  • Warm compresses help dilate the pores of the skin surface so as to accelerate heat dissipation.
  • Clothing that is thin, does not hinder the body's heat loss.
  • Clothes are damp / wet will cause inconvenience to the client.
  • Thick blanket that will hinder the body's heat loss.
  • Can help you lose body heat.