Wednesday, September 8, 2010

NCP: pneumonia

Nursing Diagnosis:
Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.

Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.

Intervention and Rationale:
I. Assess for:
  1. Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
  2. Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
  3. Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.
II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.
  1. ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.
III. Administer:
  1. Oxygen therapy via cannula - maintain optimal oxygen level.
  2. Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
  3. Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
  4. Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.
IV. Perform or Provide:
  1. Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
  2. Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
  3. Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
  4. Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
  5. Postural drainage and percussion PRN - mobilizes secretion.
  6. Suction secretions if cough ineffective - removal if unable to bring up secretions.
  7. Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.

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