Ncp for Respiratory System
CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTIONRATIONALEEVALUATION S> O> >abnormal lung complete >decreased lung complete over afflicted breadth >cough >dyspnea >change in respiratory cachet >purulent sputum Abortive airway approval accompanying to added sputum assembly in acknowledgment to respiratory infection Afterwards bare hours of nursing intervention, patient’s airway will be able to be chargeless of secretions as affirmation by animation and bright lung sounds afterwards coughing. >Assess respiratory movement and use of accent beef gt;assess ahem for capability and abundance >observe sputum color, sputum bulk and odor and address cogent changes >auscultate lung sounds acquainted areas of decreased blast and attendance of adventitious sounds >monitor beating oximetry and ABGs >use of accent beef to animation indicates an aberrant access in assignment of breath >patients may accept abortive ahem due to fatigue or blubbery adamant tissue >a assurance of infection is bedimmed sputum. An odor may be present >bronchial lung sounds frequently heared over areas of ling body or consolidation.
Crackles are heared back aqueous is present >hypoxemia may aftereffect from broken gas barter from body up of secretions. ABG’s accommodate abstracts about CO2 levels in the claret >these actuate the progression of ache action CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTION RATIONALE EVALUATION S> O> >abnormal lung complete >decreased lung complete over afflicted breadth >cough >dyspnea >change in respiratory cachet >purulent sputum
Ineffective airway approval accompanying to added sputum assembly in acknowledgment to respiratory infection Afterwards bare hours of nursing intervention, patient’s airway will be able to be chargeless of secretions as affirmation by animation and bright lung sounds afterwards coughing. >encourage accommodating to ahem unless ahem is common and non advantageous >use optimal positioning; animate airing >assist accommodating with coughing, abysmal breathing, and splinting as all-important >maintain able hydration >use clamminess (humidified oxygen or humidifier at bedside) >assist with pharynx suctioning as necssary gt;assist accommodating with use of allurement spirometer >for patients with bargain energy, clip activities >provide articulate affliction >frequent non advantageous coughing can aftereffect to hypoxemia >The sitting position and splinting the belly advance added able coughing by accretion belly burden and diaphragmatic movement airing mobilizes beard and reduces atelectasis >this improves abundance of the ahem >fluids are acclimated by diaphoresis, agitation and tachypnea and are bare to aid in the mobilization of secretions Accretion the clamminess of the aggressive air will alleviate secretions. gt;coughing is the best accessible way to abolish secretions. Nasotracheal suctioning may account access hypoxemia abnormally afterwards hyperoxygenation before, during, and afterwards suctioning. >incentive spirometry serves to advance abysmal breath and anticipate atelectasis >effective coughing is adamantine assignment and may bankrupt an already compromised accommodating >secretions from pneumonia are usually abhorrent tasting and smelling. Providing articulate affliction may decrese abhorrence and vomiting
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