Requirement in NCM 312

Presented by:
Chloie Marie C. Rosalejos
BSN 3-A

Submitted to:
Ma. Lynn C. Parambita
 NURSING CARE PLAN FOR CHRONIC BRONCHITIS

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

SUBJECTIVE: INEFFECTIVE Tracheobronchial LONG TERM INDEPENDENT: LONG TERM

BREATHING obstruction OUTCOME: OUTCOME
Stated: PATTERN Assess Respiratory ACHIEVED:
“Nahihirapan akog RELATED TO  After 2 days of respiratory rate and rate and rhythm
huminga at saka TRACHEO- nursing depth by listening to changes are After 2 days of
Amounts of fluid are
kinakapos ako sa BRONCHIAL intervention, the lung sounds. early warning nursing
drained from the
paghinga.” OBSTRUCTIO client will be able signs of intervention, the
pleural cavity
N to: impending client will be able
SECONDARY  respiratory to:
Establish a Note muscles
TO PLEURAL difficulties.
OBJECTIVE:  fluid pressure in normal/effective used for Establish a
EFFUSION AS breathing(sterno-
the pleural cavity respiratory these signify normal/effective
Dyspnea EVIDENCED cleidomastoid,
pattern AEB an increase in respiratory
BY DYSPNEA  diaphragmatic) and
Observed absence of s/s of work of pattern AEB
hypoxia, normal retractions/flaring of breathing absence of s/s of
physical Atelectasis in the
nostrils
discomfort affected side of the skin color. hypoxia, normal
lung skin color.
position client
use of
with proper body
accessory muscle 
SHORT TERM alignment(semi-
noted This is for
Impaired cardiac OUTCOME: fowler’s position) SHORT TERM
filling/inflamed good lung OUTCOME
oxygen in use
pleural membranes After 4 hours of excursion and ACHIEVED:
via nasal cannula,
nursing chest expansion
2-3L/min Ensure that
(intensified on intervention, the After 4 hours of
mucus/secretio inspiration) client will be able oxygen delivery nursing

CHLOIE MARIE C. ROSALEJOS BSN 3A

n  to: system is applied to this provides intervention, the
the patient, the adequate client will be able
production Dyspnea, difficulty verbalize appropriate amount oxygenation to to:
in breathing, altered awareness of of oxygen is prevent patient
chest excursion, causative factors verbalize
delivered from
respiratory depth awareness of
desaturation
changes demonstrate pace and causative factors
appropriate schedule activities
coping behaviors providing adequate demonstrate
like proper rest periods appropriate
Reference: Medical
breathing and coping behaviors
Surgical This prevents
coughing Encourage like proper
Nursing:Brunner dyspnea
sustained deep breathing and
11th edition, p.652 resulting from
breaths by coughing
emphasizing slow fatigue
inhalation, holding
these promote
end inspiration)
deep inspiration
Teach client
appropriate deep
breathing and
coughing
techniques
these facilitate
adequate
COLLABORATIVE: clearance of
secretions
Administer
oxygen at lowest
concentration
indicated For
management of
underlying
pulmonary

CHLOIE MARIE C. ROSALEJOS BSN 3A

 condition and
respiratory
Refer the client to distress.
a dietician and or
support groups. --.for proper
counseling and
intake of caloric
needs.

CHLOIE MARIE C. ROSALEJOS BSN 3A

 PATHOPHYSIOLOGY FOR CHRONIC BRONCHITIS

Predisposing Factors: Predisposing Factors:

Etiologic Agent: • Elderly Immobilization  Elderly Immobilization
 Bacteria • Immune Deficiency  Immune Deficiency
 Virus • Long Term illness  Long Term illness Smoking
• Smoking

Microorganism enter respiratory tract by droplet inhalation

Widespread inflammation occurs

CHLOIE MARIE C. ROSALEJOS BSN 3A

 Widespread inflammation occurs (increased goblet cells, squamous
melaplasia of columnar epithelium acute leukotic and lymphocytic
infiltration of bronchial walls)

Thin mucous lining of the bronchi can become irritated and swollen

Cells that make up this lining may leak fluids in response to the inflammation

Coughing as a reflex that works to clear secretions from the lungs

Alveolar fluid increase

CHLOIE MARIE C. ROSALEJOS BSN 3A

 Narrowing of airways

Ventilation decreases as secretion thickens

Mucus within the airways produces resistance in small always and can
cause severe ventilation- perfusion imbalance

CHLOIE MARIE C. ROSALEJOS BSN 3A