I want to pause for a while and post something from my new assignment. I want to say that this is trashes but this is too valuable. so, i decided to put in here. The picture above is explain the condition in the patient with Pneumonia.
The source is from LeMone, Priscilla. (2008). Medical-surgical Nursing (Critical Thinking in client care) (fourth edition ed.). USA: Perason education,Inc.
Table 2.1. The Nursing interventions for Patients with Pneumonia.
|Ineffective airway clearance||Assess respiratory status, including vital signs, breath sounds, SaO2, and skin color at least every 4 hours.||Early identification of respiratory compromise allows intervention before tissue hypoxia is significant.|
|Assess cough and sputum (Amount, color, consistency and possible odor)||Assessment of the cough and nature of sputum produced allows evaluation of the effectiveness of respiratory clearance and the response to therapy.|
|Monitor ABG result; report increasing hypoxemia and other abnormal result to the physician.||Blood gas changes may be an early indicator of impaired gas exchange due to airway narrowing or obstruction.|
|Place in fowler’s or high-fowlers position. Encourage frequent position changes and ambulation as allowed.||The upright position promotes lung expansion; position changes and ambulation facilitate the movement of secretions.|
|Assist to cough, deep breathe, and use assistive devices. Provide endotracheal suctioning using aseptic technique as ordered.||Coughing, deep breathing, and suctioning help clear airways.|
|Provide a fluid intake of at least 2500 to 3000 mL per day.||A liberal fluid intake helps liquefy secretions, facilitating their clearance.|
|Work with the physician and respiratory therapist to provide pulmonary hygiene measures, such as postural drainage, percussion and vibration.||These technique help mobilize and clear secretion.|
|Administer prescribed medication as ordered and monitor their effects.||If the infecting organism is resistant to the prescribed antibiotic, little improvement may be seen with treatment. Bronchodilators help maintain open airways but may have adverse effects such as anxiety and restlessness.|
|Ineffective breathing pattern||Provide for rest periods.||Rest reduces metabolic demands, fatigue, and the work of breathing, promoting a more effective breathing pattern.|
|Assess for pleuritic discomfort. Provide analgesic as ordered.||Adequate pain relief minimizes splinting and promotes adequate ventilation.|
|Provide reassurance during periods of respiratory distress.||Hypoxia and respiratory distress produce high levels of anxiety, which tends to further increase tachypnea and fatigue and decrease ventilation.|
|Administer oxygen as ordered.||Oxygen therapy increases the alveolar oxygen concentration and facilitates its diffusion across the alveolar-capillary membrane, reducing hypoxia and anxiety.|
|Teach slow abdominal breathing.||This breathing pattern promotes lung expansion.|
|Teach use of relaxation techniques, such as visualization and meditation.||These techniques help reduce anxiety and slow the breathing pattern.|
|Activity intolerance||Assess activity intolerance, noting any increase in pulse, respiration, dyspnea, diaphoresis or cyanosis.||These assessment findings may indicate limited or impaired activity intolerance.|
|Assist with self-care activities, such as bathing.||Assistance with ADLs reduces energy demands,|
|Schedule activities, planning for rest periods.||Rest periods minimize fatigue and improve activity tolerance.|
|Provide assistive devices, such as an overhead trapeze.||These assistive devices facilitate movement and reduce energy demands.|
|Enlist the family’s help to minimize stress and anxiety levels.||Stress and anxiety increase metabolic demands and can decrease activity tolerance.|
|Perform active or passive range of motion (ROM) exercises.||Exercises help maintain muscle tone and joint mobility and prevent contractures if bed rest is prolonged.|
|Provide emotional support and reassurance that strength and energy will return to normal when the infection process has resolved and the balance of oxygen supply and demand is restored.||The client may be concerned that activity intolerance will continue to be a problem after the acute infection is resolved.|