Page 4 - Altered Obstructive Nursing Care
P. 4
CikguOnline
CikguOnline
Nursing Interventions Rationale
Nursing Assessment
Establishes a baseline for monitoring
Monitor and graph serial ABGs, pulse progression or regression of disease process
oximetry, chest x-ray.
complications.
Therapeutic Interventions
Position head midline with flexion on Gain or maintain an open airway.
appropriate for age/condition.
Elevation of the head of the bed facilitates
respiratory function by use of gravity;
Assist the patient to assume a position of however, patient in severe distress will seek
comfort (elevate the head of the bed, have the position that most eases breathing.
patient lean on an overbed table or sit on edge of
the bed). Supporting arms and legs with table, pillows,
and so on helps reduce muscle fatigue and
can aid chest expansion.
Keep environmental pollution to a minimum Precipitators of an allergic type of respiratory
such as dust, smoke, and feather pillows, reactions that can trigger or exacerbate the
according to the individual situation. onset of an acute episode.
Provides patient with some means to cope
Encourage abdominal or pursed-lip breathing with or control dyspnea and reduce air-
exercises.
trapping.
Cough can be persistent but ineffective,
Observe characteristics of cough (persistent, especially if the patient is elderly, acutely ill,
hacking, moist). Assist with measures to or debilitated. Coughing is most effective in
improve the effectiveness of cough effort. an upright or in a head-down position after
chest percussion.
Hydration helps decrease the viscosity of
Increase fluid intake to 3000 mL per day within secretions, facilitating expectoration. Using
cardiac tolerance. Provide warm or tepid liquids. warm liquids may decrease bronchospasm.
Recommend the intake of fluids between, Fluids during meals can increase gastric
instead of during, meals.
distension and pressure on the diaphragm.
Demonstrate effective coughing and deep- Helps maximize ventilation.
breathing techniques.
Assist the patient to turn every 2 hours. If Movement aids in mobilizing secretions to
ambulatory, allow patient to ambulate as
tolerated. facilitate clearing of airways.
4
