1. Ineffective airway clearance related to bronchospasm, increased production of secretions, retained secretions, thick, viscous secretion, decreased energy or weakness.
The patient will maintain a patent airway with a clean or clear breath sounds
with expected outcomes: The patient will exhibit behaviors to improve airway clearance, for example; effective cough and remove secretions.
- Auscultation of breath sounds. Note the presence of breath sounds, for example; wheezing, crackles.
- Assess or breathing frequency monitor. Note the ratio of inspiration or expiration.
- Note the degree of dyspnea, such complaints of air hunger, nervousness, anxiety, respiratory distress, use of accessory muscles.
- Assess the patient to a comfortable position, for example; elevation of the head of the bed, sitting on the back of the bed.
- Encourage or aids or lips abdominal breathing exercises.
- Observation of the characteristics of the cough, for example; Settle cough, hacking cough, wet. Aid measures to improve the effectiveness of cough effort.
- Increase fluid intake to 3000 ml / day as tolerated heart. Provide warm water. Encourage fluid intake between as a meal replacement.
- Give medication as indicated.
- Analgesics, cough suppressant or antitussive.
- Provide additional humidification.
- Auxiliary treatment of respiratory, for example; chest physiotherapy.
2. Impaired gas exchange related to disturbances supply oxygen (airway obstruction by secretion, bronchospasm, traps air), damage to the alveoli.
Expected outcomes: The patient showed improvement adequate ventilation and oxygenation of tissues with blood gas analysis and free of symptoms of respiratory distress
with expected outcomes: The patient will participate in the treatment program within the level of ability or situation.
- Assess the frequency, depth of breathing. Note the use of accessory muscles, lip breathing, inability to speak or talk.
- Elevate the head of the bed, help the patient to choose a position that is easy to breathe. Encourage deep breathing or breath lips slowly as needed or individual tolerance.
- Assess regularly or watch the color of the skin and mucous membranes.
- Advise issued sputum.
- Auscultation of breath sounds, noting areas of decreased airflow and or additional noise.
- Fremitus palpation.
- Monitor the level of consciousness or mental status. Investigate the changes.
- Evaluation of the tolerance level of activity. Give calm and cool environment. Limit activity or encourage the patient to sleep or rest in a chair during the acute phase. Could the patient's activity and increase gradually as tolerated individual.
- Monitor vital signs and cardiac rhythm.
- Monitor series blood gas analysis and pulse oximetry.
- Give supplemental oxygen in accordance with an indication of the results of blood gas analysis and the patient's tolerance.
3. Imbalanced Nutrition: less than body requirements related to dyspnea, weakness, side effects of medicine, production of sputum, anorexia, nausea or vomiting.
Expected outcomes: The patient showed an increase in weight towards the right goals
with expected outcomes: The patient will show behavioral or lifestyle changes to improve or maintain proper weight.
- Assess dietary habits, food intake at this time. Note the degree of difficulty of food. Evaluation of weight and body size.
- Auscultation of bowel sounds.
- Give frequent oral care, waste discharge, provide special containers for disposable wipes.
- Encourage periods of rest for 1 hour before and after meals. Give eat small but frequent portions.
- Avoid gas-producing foods and drinks carbonates.
- Avoid foods that are very hot or very cold.
- Measure the weight as indicated.
- Consul dietician or nutrition support team to provide food that is easily digestible, nutritionally balanced, for example: additional nutrients or hose oral, parenteral nutrition.
- Assess laboratory tests such as glucose, electrolytes. Give vitamins or minerals or electrolytes as indicated.
- Give supplemental oxygen during the meal as indicated.
4. Risk for infection related to inadequate primary defenses (decreased cilia work, persistence secretions), inadequate immunity (tissue damage, increased exposure to the environment), the process of chronic disease, malnutrition.
Expected outcomes: The patient expressed understanding of the cause or risk factor and outcomes: The patient will identify interventions to prevent or lower the risk of infection and the patient will demonstrate techniques, changes in lifestyle to improve safe environment.
- Monitor body temperature.
- Assess the importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.
- Observation of color, character, smell sputum.
- Demonstrate and assist the patient on discharge of tissue and sputum. Encourage proper hand washing (nurses and patients) and use gloves when holding or disposing of tissue.
- Supervise visitors, provide masks as indicated.
- Encourage a balance between activity and rest.
- Discuss the need for adequate nutrient inputs.
- Get induced sputum by coughing or suction for gram stain, culture or sensitivity.
5. Activity intolerance related to imbalance of supply O2.
Expected outcomes: The patients showed increased tolerance for activity
with expected outcomes: Reduced complaints of shortness of breath and weak in carrying out activities.
- Monitor the pulse and frequency of breathing before and after activity.
- Make energy savings in carrying out the following procedure:
- Provide assistance in carrying out daily needs as required.
- Provide an interval of time between events to allow rest between activities.
- Increase your activity gradually in line with the increase in arterial blood gas results and can be anticipated signs and symptoms of respiratory suppression.
- Provide food in small portions but often with foods that are easy to chew.
6. Sleep pattern disturbance related to cough settled.
Expected outcomes: sleep needs are met
with expected outcomes: report feeling can rest.
- If there is a treatment for lung, arrange for the provision of medicine to be administered prior to bedtime.
- Ensure good ventilation of the room. Set procurement of air humidifier if necessary.
- Encourage the use of oxygen during sleep if necessary.
- Keep the room free of irritants such as smoke, pollen and air freshener.
- At bedtime, allow the patient shower with warm water or regular bath.
- Help the patient to obtain a comfortable position, usually by elevating the head of the bed about 30 degrees.