Nursing Care Plan for Pulmonary Atelectasis


Impaired Gas Exchange and Ineffective Airway Clearance

1. Impaired Gas Exchange related to
  • alveolar-capillary membrane dysfunction (inflammatory effect)
  • impaired oxygen-carrying capacity

Goal: patients showed improved ventilation and oxygenation of tissues

Expected outcomes:
  • gas exchange can be maintained

Interventions:

Independent :

1. Assess the depth of breathing frequency.
R / to evaluate the degree of respiratory distress or respiratory disease process.

2. Elevate head of bed, help patients choose a position that is easy to breathe, encourage the patient to deep breathing, or mouth breathing.
R / oxygen delivery can be improved with a high seating position and breathing exercises to reduce airway collapse.

3. Auscultation of breath sounds, defect area decreased airflow / noise addition, (crackles, wheezing, dim).
R / breath sounds may be dim due to reduced air flow, indicates the presence of wheezing bronchospasm.

4. Palpation fremitus (vibration vibration on palpation)
R / vibration reduction suspected fluid collection.

5. Evaluation of the level of activity tolerance.
R / for respiratory distress severe / acute, the patient is totally unable to perform daily activities

6. Monitor vital signs and cardiac rhythm.
R / tachycardia and changes in blood pressure that may indicate the existence of systemic hypoxemia on cardiac function.

Collaboration

7. Supervise / picture series blood gas analysis and pulse
R / PaCO2 usually increases (bronchitis, emphysema) and PaCO2 generally decreased, resulting in hypoxia.

8. Give supplemental oxygen in accordance degan indicative of the results of blood gas analysis and patient tolerance.
R / improve or prevent worsening hypoxia

9. Assist patients in intubation, provide / maintain mechanical ventilation.
R / occurrence of respiratory failure that requires rescue efforts will come alive.


2. Ineffective Airway Clearance related to increased production of sputum

Goal: patients exhibit achieve airway clearance.

Expected outcomes:
Clients can maintain effective airway

Independent

1. Auscultation of breath sounds, record the presence of breath sounds, eg wheezing, crackles.
R / some degree of bronchial spasms occur with airway obstruction and there adventisius breath.

2. Assess the frequency and depth of breathing chest movement
R / breathing shallow and asymmetrical chest movements often occur because of discomfort chest wall movement / lung fluid.

3. Give fluids at least 2500 ml / day, unless contraindicated, offer warm water.
R / liquid (especially hot water) to mobilize

4. Observation color skin, mucous membranes and nails
R / cyanosis nails shows the vasoconstriction, cyanosis of mucous membranes and the skin around the mouth indicates systemic hypoxemia.

Collaboration

1. Give medication as indicated
R / relaxes smooth muscle and reduce local congestion

2. Provide additional humidifier, eg ultranik nebulizer, aerosol humidifier room
R / humidity decrease the viscosity of secretions and facilitate secret spending.

3. Provide respiratory treatment, eg, chest physiotherapy
R / postural drainage and percussion parts esse

0 komentar:

Post a Comment

Popular Posts

Submit Your Site To The Web's Top 50 Search Engines for Free!