Polish up on client care

ASSESSMENT FINDINGS
Adventitious breath sounds (crackles,
rhonchi, wheezing, and pleural friction rub)
Change in mentation, anxiety
Chest pain
Cough, sputum production, hemoptysis
Cyanosis, diaphoresis
Decreased respiratory excursion,
accessory muscle use, retractions
Difficulty breathing, shortness of breath,
dyspnea, tachypnea, orthopnea
Fatigue
Nasal flaring
Tachycardia

Antibiotics: according to sensitivity of causative organism

Anticoagulant: enoxaparin (Lovenox)
Bronchodilators: terbutaline, aminophylline, theophylline (Theochron); via nebulizer: albuterol (Proventil-HFA), ipratropium
(Atrovent)
Diuretic: furosemide (Lasix) if fluid overload is the cause
Histamine-2 blockers: famotidine (Pepcid),
ranitidine (Zantac), nizatidine (Axid)
Neuromuscular blocking agents: pancuronium, vecuronium, atracurium
Steroids: hydrocortisone (Solu-Cortef),
methylprednisolone (Solu-Medrol)

83

The client
exhibits adventitious
breath sounds
and reports feeling
tired of breathing.
It could be acute
respiratory failure.

DIAGNOSTIC TEST RESULTS

ABG levels show hypoxemia, acidosis,
alkalosis, and hypercapnia.
Chest X-ray shows pulmonary infiltrates,
interstitial edema, and atelectasis.
Hematology reveals increased WBC count
and ESR.
. .
Lung scan shows V/Q ratio mismatches.
Sputum study identifies organism.

NURSING DIAGNOSES

Activity intolerance
Impaired gas exchange
Ineffective peripheral tissue perfusion
Ineffective airway clearance
Anxiety
Ineffective breathing pattern

TREATMENT
Chest physiotherapy, postural drainage
(position the client prone or supine with
the foot of the bed elevated higher than
the head for postural drainage), incentive
spirometry
Chest tube insertion, if pneumothorax
develops from high PEEP administration
Dietary changes, including establishing a
high-calorie, high-protein diet, and restricting
or encouraging fluids depending on the cause
of the disorder
O2 therapy, intubation, and mechanical
ventilation (possibly with PEEP)

Drug therapy
Anesthetic: propofol (Diprivan)
Antianxiety agent: lorazepam (Ativan)

313419NCLEX-RN_Chap04.indd 83

INTERVENTIONS AND RATIONALES

Assess respiratory status to detect early
signs of compromise and hypoxemia.
Monitor and record intake and output to
detect fluid volume excess, which may lead to
pulmonary edema.
Track laboratory values. Report deteriorating ABG levels, such as a fall in PaO2
levels and rise in PaCO2 levels. Low Hb and
HCT levels reduce oxygen-carrying capacity of
the blood. Electrolyte abnormalities may result
from use of diuretics.
Monitor pulse oximetry to detect a drop in
arterial oxygen saturation (SaO2 ).
Monitor and record vital signs. Tachycardia and tachypnea may indicate hypoxemia.
Monitor and record color, consistency,
and amount of sputum to determine hydration
status, effectiveness of therapy, and presence of
infection.
During steroid therapy, monitor blood
glucose level every 6 to 12 hours using a
blood glucose meter to detect hyperglycemia
caused by steroid use.
Administer O2 to reduce hypoxemia and
relieve respiratory distress.
Monitor mechanical ventilation to prevent
complications and optimize PaO2 .
Provide suctioning; assist with turning,
coughing, and deep breathing; perform chest
physiotherapy and postural drainage to facilitate mobilization and removal of secretions.
Maintain bed rest to reduce O2
requirement.

4/8/2010 6:46:16 PM