Ncp for Respiratory System

CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTIONRATIONALE paygrade S O unnatural lung sound decreased lung sound over affected region cough dyspnea change in respiratory status purulent stolidity Ineffective airway headway related to increase sputum production in response to respiratory infection after(prenominal) blank hours of nursing intervention, long-sufferings airway will be able to be free of secretions as certify by eupnoea and clear lung sounds after coughing. Assess respiratory movement and use of accessory muscle gtassess cough for effectiveness and productivity observe sputum color, sputum amount and odor and report significant changes auscultate lung sounds noting aras 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 powerless cough due to fatigue or thick tenacious weave a sign of in fection is discolored sputum. An odor may be bribe bronchial lung sounds normally 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 declivity 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 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 deep use optimal sending encourage ambulation assist patient with coughing, deep breathing, and spli nting 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 verbal care frequent non productive coughing can result to hypoxemia The sitting position and splinting the abdomen promote more effective coughing by change magnitude abdominal pressure and diaphragmatic movement ambulation mobilizes secretion and reduces atelectasis this improves productivity of 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 decompress secretions. gtcoughing is the most helpful way to remove secretions. Nasotracheal suctioning may deliver increase hypoxemia especially without hyperoxygenation before, during, and after suctioning. incentive spirometry serves to improve deep breathing and o ppose 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