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Ineffective Airway Clearance - Nursing Interventions for Encephalitis


Encephalitis is an inflammation of the brain. There are many types of encephalitis, most of which are caused by infections. Most often these infections are caused by viruses. Encephalitis can also be caused by diseases that cause inflammation of the brain.

The symptoms of encephalitis include sudden fever, headache, vomiting, visual sensitivity to light, stiff neck and back, confusion, drowsiness, clumsiness, unsteady gait, and easily aroused. Loss of consciousness, poor responsiveness, attacks, muscle weakness, severe dementia and a sudden memory loss can also be found in patients with encephalitis.
  • Fever.
  • Headache and usually in infants with screams.
  • Dizziness.
  • Vomiting.
  • Sore throat.
  • Malaise.
  • Pain in the extremities.
  • Pale.
  • Hallucinations.
  • Stiff neck.
  • Seizures.
  • Restless.
  • Iritable.
  • Disorders of consciousness.

Nursing Diagnosis for Encephalitis:

Ineffective airway clearance related to accumulation of secretions in the airway.

Goal:
  • Airway can be effective,
  • Adequate oxygenation.
Characterized by :
  • Respiratory frequency : 20-24 x / minute, regular rhythm, normal breath sounds, no stridor, ronchi, sheezing, no nostril breathing symmetrical chest movement, no retraction.

Intervention:
  1. Review the speed, depth, frequency, rhythm and breath sounds.
  2. Adjust the position of the client with a semi-Fowler position.
  3. Perform chest physiotherapy.
  4. Perform suction mucus carefully for 10-15 seconds. Note the nature, color and odor of secretions.
  5. Observation of vital signs, especially respiratory frequency.
  6. Collaborate with medical team in the delivery of oxygen therapy, monitor the accuracy of therapy and complications that may arise.

Rational:
  1. The changes that occur are useful in demonstrating the presence and extent of pulmonary complications of the brain affected.
  2. With this position it will reduce the bowels of the diaphragm, resulting in lung expansion is not compromised.
  3. With chest physiotherapy expected secretions can dirontokan to large airway and can be removed.
  4. The effect of the inhalation of airway secretions will clean and prevented the accumulation of respiratory secretions can be smoothly and effectively.
  5. Vital Signs is an overview of the development of the client for consideration doing the next action.
  6. Giving oxygen may improve oxygenation of the brain. Appropriateness of therapy required to prevent oxygen poisoning and respiratory tract irritation.

Pediatric Nurses