Related to:
- Tracheobronchial inflammation, edema formation, increased sputum production
- Pleuritic pain
- Decreased energy, weakness
Possible evidenced by:
- Changes in the frequency of respiratory depth
- Abnormal breath sounds, accessory muscle use
- Dyspnea, cyanosis
- Cough effective / ineffective with / without sputum production
Expected Results:
- Behavior to achieve cleanliness airway
- Showed a patent airway with breath sounds clean, no dyspnea or cyanosis
Nursing Intervention:
Independent
Collaboration
- Assess the frequency / depth of breathing and chest movement
- Pulmonary auscultation, note the areas of decreased / no air flow and additional breath sounds (cracles, wheezing)
- Help the patient to cough effectively and breath in
- Suction as indicated
- Give fluids at least 2500 ml / day
Collaboration
- Help monitor the effects of nebulizer treatment and other physiotherapy
- Give medications as indicated: mukolitik, expectorant, bronchodilator, analgesic
- Give extra fluids
- Watch the ray series 'X' chest, GDA, the pulse oximetry
- Help bronchoscopy / thoracic synthesis when indicated