chest x-ray – test for fluid, air, or atelectasis (under inflated tissue)
arterial blood gases – ABG hold pressure for 5 min on artery
sputum culture – collect in a.m. form deep within chest
pulse oximetry – use opposite side of body from BP arm
bronchoscopy – scope into lungs – sterile (must have consent)
TB skin test (PPD) check for redness, erythema, induration
Nursing Diagnoses – Ineffective Breathing pattern
R/T pain? Decreased energy?
Musculoskeletal impairment?
AEB – SOB, nasal flaring, abnormal ABG values, use of accessory muscles, cough, cyanosis
Nursing Diagnoses – Impaired Gas Exchange
R/T Imbalance of ventilation & perfusion
AEB – confusion, somnolence, restlessness, irritability, hypoxia
Outcome Identification – the client will...
mobilize pulmonary secretions
tissues will have adequate oxygenation
verbalize method to prevent recurrence of infection
Implementation – health promotion
hand hygiene
cover mouth when oughing
avoid large crowds in flu season
nutrition
rest
flu shots
Implementation
health promotion
smoking cessation guidelines ("Chantix" prescription med to aid smoking cessation)
reducing allergens
providing adequate hydration
positioning & ambulation
deep breathing
Incentive Spirometry – semi-Fowler's position, inhale & measure breath, hold 3 sec., slowly exhale
check for 8-10 breaths
Coughing & deep breathing
teach prior to surgery while pain is not an interfering factor
take 3 slow deliberate breaths
on 3rd breath, hold it
splint the incision (hold hand gently, but firmly over incision)
cough deeply two or three times
Oxygen by nasal cannula
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