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, patient’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. ABG’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, patient’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