NURSING INTERVENTIONS
Assess breath sounds, HR, and RR
Assess ABG, Oxygen saturation, Hemoglobin and Hematocrit
Position on a lateral side-lying position with the “good lung down”
Initiate pulmonary hygiene by teaching effective C&DB
Encourage pursed lipped breathing exercises.
Maintain hydration of fluids
Perform Chest PT every 2-3 hours.
Allow for rest and relaxation by scheduling appropriate intervals of treatments
Turn patient every 2 hours. Use positions tolerable by the patient without causing
dyspnea.
INDEPENDENT
- Adventitious sounds (e.g wheezes) during exhalation may be heard due to blockage of
mucus in the airway along side with decrease breath sounds because of reduced
airflow.
- Provides baseline line data to compare results to later findings and basic indicators of
respiratory effort.
Provides information to determine level of lung function, oxygen and carbon dioxide in
the blood. Helps determines deficits in oxygen delivery.
Prevents aspiration and promotes maximum intake of air and expansion of the
diaphragm.
Promotes effective forceful cough that dislodge mucus up the airways. Improves air
ventilation and allows for lung expansion.
Promotes longer opening of the alveolar to take in oxygen and removing more carbon
dioxide out of the lungs.
Thins and moisten mucus for an easier expectoration.
Helps loosen secretions for expectoration and aid postural drainage.
Prevents worsening of the condition by conserving energy and avoiding fatigue.
Enables the patient to prepare for later sessions of treatments.
Provides optimal ventilatory process and enhances gas exchange.
DEPENDENT
1. Albuterol is a bronchodilator that helps dilate the airways before engaging on
treatments for airway clearance. Given through metered dose inhalers or through
nebulizers.
2. Mannitol is a mucolytic agent that help thins out mucus in the airways.
3. Amoxicillin is a type of penicillin used to treat bacterial infections and maintain lung
function.
Maintain Adequate Nutrition. Collaborate with a dietitian to plan meals per day.
4. Small meals for a day allows the diaphragm and lungs to expand freely without being
constricted by a full stomach.
Administer medications as prescribed by the physician:
1. Albuterol
2. Mannitol
3. Amoxicillin (staph caused infection)
4.
RATIONALE