Safe, effective care environmenta.
High risk for injury b.
High risk for infection2.
Decreased cardiac output b.
Impaired gas exchangec.
Ineffective individual coping b.
Body image disturbance4.
Impaired adjustment b.
NoncomplianceGeneral Nursing Planning, Implementation, and EvaluationGoal 1: Client will maintain patent airway and adequate oxygenation.Implementation1.
Monitor respiratory status (e.g., vital signs breath sounds, skin color).2.
Limit or space activities to decrease O
Turn frequently if on bed rest.5.
Place in Fowler¶s position to increase air exchange.6.
Humidity air 7.
Cough and deep-breathe frequently.9.
Avoid sedatives that depress respirations and cough reflex (e.g., narcotics).10.
Force fluids to liquefy bronchial secretions.11.
Suction as needed; provide hyperoxygenation before and after suctioning to decrease chancesof hypoxia.12.
Carry out postural drainage to promote drainage of lung and bronchi by gravity, if needed.a.
Give humidified air or bronchodilators 10-15 minutes before. b.
Do not longer than 15 minutes at one timec.
Clapping or vibrating helps loosen secretionsd.
Avoid clapping or vibrating over sternum, breast tissue, below ribse.
Follow with coughing to be effective; do not allow client to cough in head-down positionEvaluationClient is well-oxygenated (PO
is greater than 80 mm Hg.)