Nursing Interventions for Bronchiectasis

Nursing Care Plan for Bronchiectasis


Bronchiectasis means a dilation that can not be recovered again from bronchial caused by recurrent episodes of pneumonitis and elongated, foreign body aspiration, or mass (ie. Neoplasm) that inhibit the bronchial lumen obstruction. (Hudak & Gallo, 1997).

Based on bronchography and pathology, bronchiectasis can be divided into three, namely:
  • Cylindrical bronchiectasis.
  • Fusiform bronchiectasis.
  • Saccular or cystic bronchiectasis.

  • Infection.
  • Hereditary disorder or congenital abnormalities.
  • Mechanical factors that facilitate the onset of infection.
  • Often patients have a history of pneumonia as a complication of measles, whooping cough, or other infectious diseases in childhood.

Signs and symptoms
  • Chronic cough with sputum that is a lot, especially in the morning, after sleeping.
  • Cough with sputum accompanying cold cough for 1-2 weeks or no symptoms at all (mild Bronchiectasis)
  • Persistent cough with sputum that is much less than 200-300 cc, accompanied by fever, no appetite, weight loss, anemia, pleural pain, and weak body sometimes shortness of breath and cyanosis, sputum often contain blood spots, and coughing up blood.
  • Found finger-clubbing in 30-50% of cases.

Nursing Care Plan for Bronchiectasis

Nursing Diagnosis for Bronchiectasis

Ineffective airway clearance related to the increased production of secretions, thick secretions.

Goal: retain patent airway with breath sounds clean / clear.

Expected outcomes:
Shows the behavior to improve airway clearance (effective cough, and issued a secret.

1. Assess / monitor respiratory frequency. Note the ratio of inspiration and expiration.
R /: Tachipneu common to some degree can be found at the reception or immersion stress / acute infection process. Slowed breathing and elongated compared inspiration expiration frequency.

2. Auscultation of breath sounds and record their breath sounds
R /: The degree of bronchospasm occurs with airway obstruction and can / do not manifested their breath sounds.

3. Assess the patient to a comfortable position, high headboard and sat at the back of the bed.
R /: Elevation of the head of the bed easier for respiratory function by using gravity. And make it easier to breathe and helps reduce muscle weakness and can be as a tool chest expansion.

4. Help abdominal breathing exercises or lips.
R / To cope with and control dyspnea and lower air entrapment.

5. Observe the characteristic cough and aid measures for the effectiveness of efforts to cough.
R / Knowing the effectiveness of cough.

6. Enter the liquid till 3000ml / day according to the tolerance of the heart, as well as provide a warm and fluid intake between as a meal replacement.
R /: Hydration helps to lower the viscosity of the secret, warm facilitate discharge can reduce bronchospasm. Liquids between meals can increase gastric distension and pressures diaphragm.

7. Give the drug as indicated.
R /: Speed up the process of healing.

Anxiety and Disturbed Sleep Pattern - Nursing Interventions for Heart Failure

Nursing Diagnosis for Heart Failure : Anxiety related to tissue oxygenation disorders, stress due to difficulty in breathing and the knowledge that the heart is not functioning properly.
characterized by; anxiety, fear, worry, stress-related illness, anxiety, anger, irritability.

Goal: The patient does not feel anxious.
with expected outcomes:
  • The patient said that anxiety decreased to a level that can be overcome.
  • The patient demonstrated problem-solving skills and know the feeling.

  • Provide the opportunity for the patient to express feelings.
  • Encourage friends and family to consider patients as before.
  • Tell patient medical programs that have been made to lower the impending attack and increase the stability of the heart.
  • Help the patient a comfortable position to sleep or rest, limit visitors.
  • Collaboration for the administration of sedatives and tranquiliser.

Rationale :
  • Statement of the problem can reduce tension, classify the level of coping and facilitate understanding of feelings.
  • Reassure patients that role in the family and work unchanged.
  • Encourage the patient to control symptoms, improve confidence in the medical program and integrate capabilities in self-perception.
  • Creating an atmosphere that allows the patient to sleep.
  • Help the patient relax until physically able to make adequate coping strategies.

Nursing Diagnosis for Heart Failure : Disturbed Sleep Pattern related to waking up frequently secondary to respiratory disorders (tightness, cough).characterized by; lethargy, insomnia, shortness of breath and coughing during sleep.

Goal: The patient can sleep more comfortably.

Interventions :
  • Raise the head of the bed 20 -30 cm. Chock forearm with a pillow.
  • In patients with orthopnea, the patient is seated on the side of the bed with both feet supported on the seat, head and put on the table bed and lumbosacral vertebrae supported by a pillow.

Rationale :
  • Venous return to the heart is reduced, pulmonary congestion is reduced and the suppression of the liver to the diaphragm is reduced and reducing muscle fatigue shoulder.
  • Reduce difficulty breathing and reduces the flow back to the heart.

Source :

Nursing Interventions for Tetralogy of Fallot

Nursing Diagnosis : Decreased Cardiac Output r / t ineffective circulation, secondary to the presence of cardiac malformations

Goal: Children can maintain adequate cardiac output


  • Vital signs are normal with age.
  • There is no dyspnea, rapid breathing and deep, cyanosis, anxiety / lethargy, tachycardia, murmurs.
  • Clients composmetis.
  • Akral warm.
  • Peripheral pulse strong and equal on both extremities.
  • Capillary refill time less than 3 seconds.
  • Urine output of 1-2 ml / kg / hour.

  1. Monitor vital signs, peripheral pulses, capillary refill by comparing measurements at both extremities while standing, sitting and lying down if possible.
  2. Assess and record the apical pulse for 1 full minute.
  3. Observation of cyanotic attacks.
  4. Give a knee-chest position in children.
  5. Observe for signs of decreased sensory: lethargy, confusion, and disorientation.
  6. Monitor intake and output adequately.
  7. Provide adequate rest time for children and accompany children during activity.
  8. Serve foods that are easily digestible and reduce the consumption of caffeine.
  9. Collaboration in the examination serial ECGs, chest radiographs, administration of anti dysrhythmias.
  10. Collaboration of oxygen.
  11. Collaboration IV fluid administration.
Source :

Nursing Interventions for Chronic Pain

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months (NANDA); a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years (Bonica, 1990)

Defining Characteristics:

Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). Clients with cognitive abilities who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify their current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).

Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.

Related Factors:
Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)
NOTE: The cause of chronic nonmalignant pain may not be known because pain is a new science and an area of diverse types of problems.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Pain Level
Pain Control
Comfort Level
Pain: Disruptive Effects

Client Outcomes

Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary (if client has cognitive abilities)
Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies
Demonstrates ability to pace self, taking rest breaks before they are needed
Functions on an acceptable ability level with minimal interference from pain and medication side effects (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Pain Management, Analgesic Administration

Read More :
Nursing Interventions and Rationales for Chronic Pain

NANDA Nursing

Care Plan Nursing