Ncp for Respiratory System

CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTION principleEVALUATION S O abnormal lung sound decreased lung sound over affected area spit up dyspnea change in respiratory status purulent lethargy Ineffective airway clearance related to increased indifference production in response to respiratory infection After blank hours of nursing intervention, diligents airway will be commensurate to be free of secretions as evidence by eupnea and clear lung sounds after cough. Assess respiratory run and design of accessory brawniness gtassess cough for effectiveness and productivity observe sputum color, sputum gist 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 whitethorn have ineffective cough due to fatigue or thick tenacious tissue a sign of inf ection is discolored sputum. An odor may be move over 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. ABGs 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 sputumIneffective airway clearance related to increased sputum production in response to respiratory infection After blank hours of nursing intervention, patients airway will be satisfactory 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 bre athing, and splinting as undeniable maintain adequate hydration use humidity (humidified oxygen or humidifier at bedside) assist with pharynx suctioning as necssary gtassist 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 sit position and splinting the abdomen promote more effective coughing by increasing abdominal twinge and diaphragmatic movement ambulation mobilizes secretion and reduces atelectasis this meliorates productivity of the cough fluids are used by diaphoresis, fever and tachypnea and are ask to aid in the mobilization of secretions Increasing the humidity of the inspired air will loosen secretions. gtcoughing 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