Ncp for Respiratory System

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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

>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 discolored 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...
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