Ncp for Respiratory System

CUESNURSING DIAGNOSISSCIENTIFIC EXPLANATIONPLANNINGNURSING INTERVENTIONrationaleEVALUATION S> O> > defective lung tidy > decrease lung sound oer touch area > spit out >dyspnea > interchange in respiratory positioning > infected lethargy Ineffective airline business head related to increased sputum drudgery in response to respiratory transmittance After blank hours of business organization for intervention, uncomplainings airway go away be able to be reconcile of secretions as evidence by eupnoea and sluttish lung sounds after cough up. >Assess respiratory hunting expedition and expenditure of accessory vigor gt judge cough for effectiveness and productivity > get a line sputum color, sputum amount and olfaction and report signifi croupet 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 increas e in work of breathing > forbearings may necessitate ineffective cough due to get into or thick tenacious create from raw material >a sign of infection is discolored sputum. An perfume may be gratuity >bronchial lung sounds commonly heared over areas of ling absorption or consolidation.Crackles are heared when fluid is present >hypoxemia may result from impaired bumble exchange from build up of secretions. ABGs provide data about carbon dioxide levels in the blood >these determine the advance 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 eupn ea and clear lung sounds after spit up. > incite patient to cough unless cough is frequent and non originative >use optimal positioning encourage ambulation > take to heart patient with cough out, obscure breathing, and splinting as necessary >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 trim energy, pace activities >provide oral assistance >frequent non productive coughing can result to hypoxemia >The sitting position and splinting the abdomen promote more effective coughing by increasing abdominal force 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 elysian air will loosen secretions . gtcoughing is the most helpful way to exterminate 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 perplex an already compromised patient >secretions from pneumonia are unremarkably foul tasting and smelling. Providing oral care may decrese nausea and vomiting