Bronchitis Nursing Care Plan
Ineffective Airway Clearance
Assessment
Patient may manifest
Wheezes/crackles on auscultation on the BLF
Subcostal retraction
Nasal flaring
Presence of non-productive cough
Increase RR above normal range
Nursing Diagnosis
Ineffective Airway Clearance
Outcomes
Patient will demonstrate effective clearing of secretions.
Patient will maintain effective airway clearance.
Nursing Interventions
Position head midline with flexion on appropriate for age/condition
Rationale: To gain or maintain open airway
Elevate HOB
Rationale: To decrease pressure on the diaphragm and
enhancing drainage
Observe S/Sx of infections
Rationale: To identify infectious process
Auscultate breath sounds & assess air mov’t
Rationale: To ascertain status & note progress
Instruct the patient to increase fluid intake
Rationale: To help to liquefy secretions.
Demonstrate effective coughing and deep-breathing techniques.
Rationale: To maximize effort
Keep back dry
Rationale: To prevent further complications
Turn the patient q 2 hours
Rationale: To prevent possible aspirations
Demonstrate chest physiotherapy, such as bronchial tapping when
in cough, proper postural drainage.
Rationale: These techniques will prevent possible
aspirations and prevent any untoward complications
Administer bronchodilators if prescribed.
Rationale: More aggressive measures to maintain airway
patency.
Ineffective Breathing Pattern
Assessment
Patient may manifest
Wheezes/crackles on auscultation on the BLF
Subcostal retraction
Nasal flaring
Presence of non-productive cough
Increase RR above normal range
Nursing Diagnosis
Ineffective Breathing Pattern RT Retained Secretions
Outcomes
Patient will improve breathing pattern.
Patient will maintain a respiratory rate within normal limits.
Nursing Interventions
Place patient in semi-fowlers position
Rationale: To have a maximum lung expansion
Increase fluid intake as applicable
Rationale: To liquefy secretions
Keep patient back dry
Rationale: To avoid stasis of secretions and avoid further
complication
Change position every 2 hours
Rationale: To facilitate secretion mov’t and drainage
Perform CPT
Rationale: To loosen secretion
Place a pillow when the client is sleeping
Rationale: To provide adequate lung expansion while
sleeping.
Instruct how to splint the chest wall with a pillow for comfort during
coughing and elevation of head over body as appropriate
Rationale: To promote physiological ease of maximal
inspiration
Maintain a patent airway, suctioning of secretions may be done as
ordered
Rationale: To remove secretions that obstructs the airway
Provide respiratory support. Oxygen inhalation is provided per
doctor’s order
Rationale: To aid in relieving patient from dyspnea
Administer prescribed cough suppressants and analgesics and be
cautious, however, because opioids may depress respirations more
than desired.
Rationale: To promote deeper respirations and cough
Impaired Gas Exchange
Assessment
Patient may manifest
Appearance of bluish extremities when in cough (cyanosis), lips
Lethargy
Restlessness
Hypercapnea
Hypoxemia
Abnormal rate, rhythm, depth of breathing
Diaphoresis
Nursing Diagnosis
Impaired Gas Exchange RT Altered Oxygen Balance
Outcomes
Patient will improve ventilation and adequate oxygenation of tissues
Patient will minimize or totally be free of symptoms of respiratory
distress.
Nursing Interventions
Monitor level of consciousness or mental status
Rationale: Restlessness,anxiety, confusion, somnolence
are common manifestation of hypoxia and hypoxemia.
Assist the client into the High-Fowlers position
Rationale: The upright position allows full lung excursion
and enhances air exchange
Increase patient’s fluid intake
Rationale: To help liquefy secretions
Encourage expectoration
Rationale: To eliminate thick, tenacious, copious
secretions which contribute for the impairment of gas
exchange.
Encourage frequent position changes
Rationale: To promote drainage of secretions
Encourage adequate rest & limit activities to within client tolerance
Rationale: Helps limit oxygen needs/consumption
Promote calm/restful environments
Rationale: To correct/improve existing deficiencies
Administer supplemental oxygen judiciously as indicated
Rationale: May correct or prevent worsening of hypoxia.
Administer meds as indicated such as bronchodilators
Rationale: To treat the underlying condition
Sleep Pattern Disturbance
Assessment
Patient may manifest
Irritability
Restlessness
Lethargy
Changes in posture
Difficulty of breathing which worsens at night
Nursing Diagnosis
Sleep Pattern Disturbance RT Difficulty of Breathing
Outcomes
Patient will identify individually appropriate interventions to promote
sleep.
Patient will be able to report improvements in sleep/rest pattern.
Nursing Interventions
Monitor level of consciousness or mental status
Rationale: Restlessness, anxiety,confusion, somnolence
are common manifestation of hypoxia and hypoxemia.
Promote comfort measures such as back rub and change in
position as necessary
Rationale: To provide non pharmacologic management
Observe provision of emotional support
Rationale: Lack of knowledge and problems, relationships
may create tension. Interfering with sleep routines based
on adult schedules may not meet child’s needs.
Provide quiet environment.
Rationale: To promote an environment conducive to sleep.
Increase patient’s fluid intake
Rationale: To help liquefy secretions
Encourage expectoration
Rationale: To eliminate thick, tenacious, copious
secretions which contribute for the DOB
Limit the fluid intake in evening if nocturia is a problem
Rationale: To reduce need for nighttime elimination
Obtain feedback from SO regarding usual bedtime, rituals/routines
Rationale: To determine usual sleep patterns & provide
comparative baseline
Provide safety for patient sleep time safety
Rationale: To promote comfort/safety
Recommend mid morning nap if one required
Rationale: Napping esp. in the afternoon can disrupt
normal sleep pattern
Administer pain medication as ordered.
Rationale: To relieve discomfort and take maximum
advantage of sedative effect
Risk for Spread of Infection
Assessment
Patient may manifest
Body temperature above normal range
Dehydration
Increase WBC count
Presence of increase mucus production
Nursing Diagnosis
Risk for Spread of Infection RT Stasis of Secretions & Decreased
Ciliary Action
Outcomes
Patient will identify interventions to prevent and/or reduce the risk
of infection
Patient will have minimize or totally be free from the risk of
infection.
Nursing Interventions
Review importance of breathing exercises, effective cough, frequent
position changes, and adequate fluid intake
Rationale: These activities promote mobilization and
expectoration of secretions to reduce the risk of
developing pulmonary infection.
Turn the patient q 2 hours
Rationale: To facilitate secretion mov’t and drainage
Encourage increase fluid intake
Rationale: To liquefy secretions
Stress the importance of handwashing to SO’s
Rationale: Handwashing is the primary defense against
the spread of infection
Teach the SO’s how to care for and clean respiratory equipment
Rationale: Water in respiratory equipment is a common
source of bacterial growth
Teach the SO’s the manifestations of pulmonary infections (change
in color of sputum, fever, chills) , self-care and when to call the
physician
Rationale: Early recognition of manifestations can lead to
a rapid diagnosis.
Recommend rinsing mouth with water
Rationale: To prevent risk of oral candidiasis.
Administer antimicrobial such as cefuroxime as indicated.
Rationale: Given prophylactically to reduce any possible
complications
Other Possible Nursing Care Plans
High risk for suffocation
High risk for aspiration
Anxiety RT acute breathing difficulties
Activity Intolerance RT inadequate oxygenation
Imbalanced Nutrition: Less than body requirements RT reduced
appetite and dyspnea (for emphysema)
