Page 7 - Altered Obstructive Nursing Care
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Nursing Interventions Rationale
Nursing Assessment
Pulse oximetry reading of 87% below may
Monitor O2 saturation and titrate oxygen to indicate the need for oxygen administration
maintain Sp02 between 88% to 92%. while a pulse oximetry reading of 92% or
higher may require oxygen titration.
As the patient’s condition progresses, Pa02
usually decreases. For patients with chronic
Monitor arterial blood gasses values as carbon dioxide retention may have chronically
ordered. compensated respiratory acidosis with a low
normal pH and a PaCo2 higher than 50 mm
Hg.
Therapeutic Intervention
Thick, tenacious, copious secretions are a
major source of impaired gas exchange in
Encourage expectoration of sputum; suction
when needed. small airways. Deep suctioning may be
required when the cough is ineffective for
expectoration of secretions.
Elevate the head of the bed, assist the patient to Oxygen delivery may be improved by upright
assume a position to ease work of breathing. position and breathing exercises to decrease
Include periods of time in a prone position as airway collapse, dyspnea, and work of
tolerated. Encourage deep-slow or pursed-lip breathing. Use of prone position to increase
breathing as individually needed or tolerated. Pao2.
During severe, acute or refractory respiratory
distress, the patient may be totally unable to
Evaluate the level of activity tolerance. Provide perform basic self-care activities because of
a calm, quiet environment. Limit patient’s
activity or encourage bed or chair rest during hypoxemia and dyspnea. Rest interspersed
with care activities remains an important part
the acute phase. Have patient resume activity of the treatment regimen. An exercise program
gradually and increase as individually is aimed at increasing endurance and strength
tolerated.
without causing severe dyspnea and can
enhance a sense of well-being.
Evaluate sleep patterns, note reports of
difficulties and whether patient feels well Multiple external stimuli and the presence of
rested. Provide quiet environment, group care dyspnea may prevent relaxation and inhibit
or monitoring activities to allow periods of
uninterrupted sleep; limit stimulants such sleep.
as caffeine; encourage position of comfort.
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