Thursday, August 15, 2019
Ncp for Respiratory System
CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTIONRATIONALEEVALUATION S> O> >abnormal lung sound >decreased lung sound over affected area >cough >dyspnea >change in respiratory status >purulent sputum Ineffective airway clearance related to increased sputum production in response to respiratory infection After blank hours of nursing intervention, patientââ¬â¢s airway will be able to be free of secretions as evidence by eupnea and clear lung sounds after coughing. >Assess respiratory movement and use of accessory muscle gt;assess cough for effectiveness and productivity >observe sputum color, sputum amount and odor and report significant changes >auscultate lung sounds noting areas of decreased ventilation and presence of adventitious sounds >monitor pulse oximetry and ABGs >use of accessory muscle to breath indicates an abnormal increase in work of breathing >patients may have ineffective cough due to fatigue or thick tenacious tissue >a sign of infection is d iscolored sputum. An odor may be present >bronchial lung sounds commonly heared over areas of ling density or consolidation. Crackles are heared when fluid is present >hypoxemia may result from impaired gas exchange from build up of secretions. ABGââ¬â¢s provide data about CO2 levels in the blood >these determine the progression of disease process CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTION RATIONALE EVALUATION S> O> >abnormal lung sound >decreased lung sound over affected area >cough >dyspnea >change in respiratory status >purulent sputum Ineffective airway clearance related to increased sputum production in response to respiratory infection After blank hours of nursing intervention, patientââ¬â¢s airway will be able to be free of secretions as evidence by eupnea and clear lung sounds after coughing. >encourage patient to cough unless cough is frequent and non productive >use optimal positioning; encourage ambulation >assist patient with coughing, deep breathing, and splinting as necessary >maintain adequate hydration >use humidity (humidified oxygen or humidifier at bedside) >assist with pharynx suctioning as necssary gt;assist patient with use of incentive spirometer >for patients with reduced energy, pace activities >provide oral care >frequent non productive coughing can result to hypoxemia >The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal pressure and diaphragmatic movement ambulation mobilizes secretion and reduces atelectasis >this improves productivity o f the cough >fluids are used by diaphoresis, fever and tachypnea and are needed to aid in the mobilization of secretions Increasing the humidity of the inspired air will loosen secretions. gt;coughing is the most helpful way to remove secretions. Nasotracheal suctioning may cause increase hypoxemia especially without hyperoxygenation before, during, and after suctioning. >incentive spirometry serves to improve deep breathing and prevent atelectasis >effective coughing is hard work and may exhaust an already compromised patient >secretions from pneumonia are usually foul tasting and smelling. Providing oral care may decrese nausea and vomiting
Subscribe to:
Post Comments (Atom)
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.