Minggu, 26 Agustus 2012


After my last post about nursing care in patients with lung abscess this time I was sharing about nursing care in patients with bronchiectasis.
Have a look below and do not forget his comments as the assessment:
A. Understanding.
 Bronchiectasis is a morphological abnormality consisting of an abnormal widening of the bronchi and settling caused damage elastic and muscular components of the bronchial wall (Soeparman & Sarwono, 1990)
 Bronchiectasis means a dilatation which can not be recovered again from bronchial caused by recurrent episodes pnemonitis and elongated, foreign body aspiration, or mass (eg, neoplasm) that inhibits the bronchial lumen obstruction (Hudak & Gallo, 1997).
 Bronchiectasis is a permanent abnormal dilatation of one or more branches of a large-vabang bronchus (Barbara E, 1998).

B. Classification
Based on bronkografi and bronchiectasis pathology can be divided into three, namely:
1. Cylindrical bronchiectasis
2. Fusiform bronchiectasis
3. Cystic or saccular bronchiectasis.

C. Etiology
1. Infection
2. Heriditer disorders or abnormalities konginetal
3. Mechanical factors that facilitate the emergence of infectious
4. Many patients have a history of pneumonia as a complication of measles, whooping cough, or other infectious diseases in childhood.

E. Clinical
Bronchiectasis is a disease that is often found at a young age, 69% of patients aged less than 20 years. Symptoms began in childhood, 60% of patients with onset of symptoms at the age less than 10 years. Symptoms depend of the area, weight, location of the presence or absence of complications.

F. Signs and Symptoms
1. Chronic cough with sputum that much, especially in the morning, after lie and lie.
2. Cough with sputum cough accompanying a cold for 1-2 weeks or no symptoms at all (mild Bronchiectasis)
3. Continuous cough with sputum a lot more than 200-300 cc, fever, no appetite, weight loss, anemia, pleural pain, and weak bodies sometimes shortness of breath and cyanosis, sputum often contains blood, and coughing up blood.
4. Discovered clubbing fingers in 30-50% of cases.

G. Diagnostic Examination
1. Pemerisaan Laboratory.
 sputum examination include sputum volume, sputum color, cells and bacteria in the sputum.
If there is infection sputum volume increases, and becomes purulent and contains more leukocytes and bacteria. Sputum culture can produce normal flora of the nasopharynx, streptococcus pneumoniae, haemophilus influenza, stapilokokus aereus, klebsiela, aerobakter, proteus, pseudomonas aeroginosa. If found foul smelling sputum suggests anaerobic infection.
 Examination of peripheral blood.
Usually found in the normal range. Sometimes found any showed leukocytosis and anemia active suppuration indicate a chronic infection.
 Checking urina
Found in the normal range, sometimes found any significant proteinuria caused by amyloidosis, however serum immunoglobulins are usually within normal limits Kadan may increase or decrease.
 ECG examination
Normal ECG within normal limits except in advanced cases korpulmonal existing complications or signs of cardiac stimulation. Spirometry in mild cases may be normal, but in severe cases there are abnormalities obstruction with reduced forced expiratory volume in 1 minute or decreased vital capacity, usually accompanied by respiratory insufficiency can lead to:
 ventilation and perfusion imbalance
 Increase alveoli pressure difference-arterial PO2
 Hypoxaemia
 hypercapnia
 Additional examination to determine predisposing factors do pemerisaan:
o Examination of immunological
o Examination of spermatozoa
o Biopsy of bronchial and nasal mucosa (bronchopulmonary repeated).

2. Radiological examination.
• Photo Chest PA and Lateral
Usually found corakan lung becomes more rugged and corakan boundaries become blurred, clustered, sometimes there is a picture and description of cystic honeycomb and limits air surface liquid. Most of the lobe of the left lung, because it has a smaller diameter and is located right across the mediastinum, lingual segment of the left upper lobe and medial lobe of the right lung.
• Examination bronkografi
Bronkografi not routinely done, but if there is an indication in which to evaluate the patient to be operated on a limited pendereita with pneumonia and recurrent somewhere that showed no clinical improvement after receiving conservative treatment or patients with massive hemoptysis.
Bronkografi done sertalah stable state that, through the administration of antibiotics and postural drainage are adequate so that the net bronchial secretions ..

H. Management
The goal of treatment is to improve the drainage of secretions and treat infections.
Management includes:
• Giving antibiotics with broad spekrum (Ampisillin, co-trimoxazole, or amoxicillin) for 5-7 days delivery
• Postural Drainage and physiotherapy exercises for pernafasan.serta effective cough to remove secretions maximum
At the time of the drainage needs to be given bronchodilators to prevent bronchospasm and improve drainage of secretions. And conducted adequate hydration to prevent the secretions to become thick and comes with a humidifier and nebulizer to moisten secretions.


A. Assessment of baseline data
1. History or adeanya contributing factors
• Smoking tobacco products as a factor leading cause
• Live or work areas with heavy air pollution
• History of allergies in the family
• There is a history of acid in childhood
2. History or presence of trigger factors such exacerbations:
• Allergen (pollen, dust, skin, pollen or mold)
• Emotional sress
• Excessive physical activity
• Air pollution
• Respiratory Infections
• Failure of recommended treatment program
3. Physical examination by focusing on the respiratory system include:
 Assess respiratory rate and rhythm
 inspections skin tone and color menbran mucosal
 Auscultation of breath sounds
 Ensure that patients using accessory muscles when breathing:
 Shrug during breathing
 retraction abdominal muscles during breathing
 Respiratory nostril
 Assess if the chest expansion is symmetrical or asymmetrical
 Assess if chest pain on breathing
 Assess cough (whether productive or nonproductive). When you specify the color of sputum productive.
 Determine if the patient has dyspnoea or orthopneu
 Assess the level of consciousness.
4. Diagnostic tests include:
 Arterial blood gas (GDA) showed low PaO2 and high PaCO2
 memunjukkan chest X-rays and lung capacity backup volumes
 Klutur sputum positive when there is infection
 Essay imunoglobolin showed an increase in serum IgE
 Pulmonary function tests to find the cause of dyspnoea and determine whether abnormal lung function (obstruction or restriction).
 Test hemoglobolin.
 EKG (P wave elevation in leads II, III, AVF and vertical axis.
5. Assess the patient's self-perception
6. Assess weight and average input fluid and diet.

B. Nursing Diagnosis
1. Ineffective airway clearance related to increased production of viscous secretions or secretion
2. Impaired gas exchange related to oxygen supply disruption and damage to the alveoli
3. Changes in nutrition less than body requirements related to nausea, vomiting, sputum production, dyspnoea
4. High risk of infection associated with the chronic disease, malnutrition.
5. Anxiety related to fear of difficulty in breathing during an exacerbation phase, lack of knowledge about treatment to be carried out
6. Activity intolerance related to damage to gas exchange

C. Intervention.
1. Ineffective airway clearance related to increased production of secretions, viscous secretions.
       Maintains a patent airway with breath sounds clean / clear.
Expected outcomes:
Showed behavior to improve airway clearance (effective cough, and issued a secret.
Plan of Action:
1. Assess / monitor pernafasan.Catat frequency ratio of inspiratory and expiratory
R / Tachipneu common to some degree can be found at the reception or immersion stress / acute infection process. Breathing slows and frequency than the expiratory lengthening inspiration
2. Auscultation of breath sounds and note the presence of breath sounds
R / degree of bronchial spasms occur with airway obstruction and may / not manifested any breath sounds.
3. Assess the patient to a comfortable position, Height head of the bed and sat on the back of the bed
R / head of bed elevation facilitate respiratory function by using gravity. And easier to breathe and helps reduce muscle weakness and can be as a tool chest expansion.
4. Bantu or lips abdominal breathing exercises
R / In order to cope with and control the dyspnoea and reduce air entrapment
5. Observation karakteriktik cough and Bantu measures for effectiveness of cough effort
R / Knowing keefktifan cough
6. Depth of fluid intake as tolerated till 3000ml/hari heart and give it a warm and fluid intake between meals in lieu of
R / Hydration helps decrease the viscosity secret, easy warm pengeluaran.cairan can decrease bronchial spasms. Liquids between meals can increase gastric distension and diaphragmatic pressures.
7. Give medication as indicated
R / Speeding up the healing process.

2. Impaired gas exchange related to oxygen supply disruption and damage to the alveoli.

         Objective: Demonstrate improved ventilation and adequate tissue oxygenation with GDA in the normal range and free of symptoms of respiratory distress.
GDA within normal limits, improved skin tone, frequency of breath 12 - 24x/mt, clean breath sounds, no coughing, 60-100x/mt pulse, no dyspnoea.
  Plan of Action:
1. Assess the frequency, depth of breathing and note the use of accessory muscles
R / to evaluate the degree of distress pernafsan / chronic illness.
2. Tingikan headboard and Help to choose a position that is easy to breathe. Kaji / watch regularly the skin and mucous membrane color
R / oxygen supply can be improved by a high seating position and breathing exercises to reduce airway collapse.
3. Push for spending sputum / suction when indicated
R / Sputum disrupt gas exchange process and the exploitation done when coughing ineffective.
4. Keep an eye on the level of consciousness / mental status
R / common manifestation of hypoxia
5. Monitor vital signs and cardiac status
R / Changes in blood pressure shows the effect of systemic hypoxia on cardiac function
6. Provide supplemental oxygen and maintain mechanical ventilation and intubation Bantu
R / can fix or prevent the occurrence of hypoxia and respiratory failure as well as for life-saving actions.

3. Changes in nutrition less than body requirements related to nausea, vomiting, sputum production, dyspnoea
Objective: Increase the nutritional status of the patient and asks

Expected outcomes:
The patient did not experience further weight loss or maintaining weight.

      Plan of action:
1. Monitor input and output every 8 hours, the amount of food consumed and body heavy weights every week.
R / To identify progress or deviations from expected
2. Create a pleasant atmosphere, an environment free of odor during meal time
R / atmosphere and environment odor during meal time can meyebakan anorexia
3. Refer patient to a dietitian to plan meals that will monitor consumption
R / can help patients with a nutritional meal plan accordingly.
4. Encourage clients to drink at least 3 liters of fluid per day, if it does not receive an infusion.
R / to treat dehydration in patients

4. High risk of infection associated with the chronic disease, malnutrition.

Purpose: It does not happen / any symptoms of infection

Expected outcomes:
No infection tbuh temperature range 36-37 0c, white blood cells 5000-10000/mm.batuk nothing productive.

      Intervention plan:
1. Monitor the patient's temperature every 4 hours, sputum culture results and the results of leokusit well as the color and consistency of sputum
R / To identify the progress that can be achieved and the deviation from the expected target (possible infection).
2. Do check sputum for culture.
R / can help establish the diagnosis of respiratory infections and identify germs cause.
3. Provide adequate nutrition yan
R / malnutrition can affect general health and lower resistance to infection.
4. Give antibiotics as directed and evaluation of effectiveness
R / For the prevention and treatment of infection and speeding the healing process.

5. Anxiety related to fear of difficulty in breathing during an exacerbation phase, lack of knowledge about treatment to be carried out.

Objective: Loss of anxiety

Expected outcomes: relaxed facial expression, breathing frequency between 12-24 x / mt, 60-100x/mt pulse.

Nursing Intervention:
1. During the period of acute respiratory distress:
 Limit the number and frequency of visitors
 Starting give oxygen through a cannula by 2 ltr / mt
 Demontrasikan to control breathing
 Allow someone to accompany the patient
 Maintain Fowler position with the position of the arm supporting
R / Helping the patient to control the situation by increasing relaxation and increase the amount of air entering the lungs
2. Avoid giving information and instructions bertele-tele/sederhana possible when patients experience distress and do approach with the patient in a calm and convincing.
R / patient may receive less information in a state of anxiety and too much information can increase anxiety and memberitauhkan what diharpkan makakan can help decrease anxiety.
3. Use medications within their prescribed sedatives.
R / Tranquilizers can control the level of ansietasnya.

6. Activity intolerance related to damage to gas exchange
Objective: The client showed increased tolerance to activity
Expected outcomes:
 The decline in complaints about shortness of breath and weak in implementing activities
Action Plan
1. Monitor pulse and breathing frequency before and after activity
R / Identify deviations kemabali expected goals
2. Provide assistance in carrying out the activity as necessary and done in stages
R / can reduce excessive energy use
3. Instruct food in small portions but often with foods that are easily chewed.
R / food in large portions sasah chewed and requires a lot of energy


Sarwono Soeparman & W, (1998), Studies of illness in Volume II Publisher FKUI Hall, Jakarta

Barbara E., (1999), Plan for Medical-Surgical Nursing care Volume I, EGC, Jakarta

Barbara E., (1999), Plan for Medical-Surgical Nursing care Volume III, EGC, Jakarta

Barbara C. long, (1996), Medical Surgical Nursing: a nursing process approach, Miscellaneous Language Foundation alumni associations bandung nursing education, IAPK Foundation, London

Hudak & Gallo, (1997), Critical Nursing: A Holistic Approach, EGC, Jakarta

Marylin E Doengoes. (2000). Nursing care plans guidelines for Perencnaan / documentation of Patient Care. EGC.Jakarta.

3 komentar:

  1. Bronchiectasis is now treatable and can be kicked away with the help of Talsical a well-researched herbal formula designed by expert herbalists to improve the condition of large airways in the body destructed due to this disorder.

  2. Bronchiectasis is a remedial disorder that is caused by destruction of the muscle and elastic tissues. Creseton fights the condition and helps you get rid of the disease gradually. It is a herbal medication that fights slowly but eliminates the disease from your system completely.

  3. Bronchiectasis is a condition where the bronchial tubes of your lungs are for all time harmed and augmented. Bronchiectasis is treatable, however it can't be cured. With Bronchiectasis Treatment you can carry on with an ordinary life.