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Nursing Diagnosis and Interventions
Nursing Diagnosis and Interventions
Nursing Diagnosis and Interventions
DIAGNOSIS
1. Ineffective breathing pattern related to rapidly
progressive weakness and impending respiratory
failure
INTERVENTIONS RATIONALE
Maximize respiratory incentive spriromertry
function with incentive aids in the lung
spirometry expansion to prevent
lung collapse or
atelectasis
Perform chest chest physiotherapy
physiotherapy (e.g. therapy helps in
vibration and cupping) immobilizing and proper
drainage of secretions
Perform deep breathing strengthens respiratory
and cupping exercises muscles, facilitates full
lung expansion and
coughing out secretions
Administer oxygen
therapy to supply enough oxygen
to body tissues and
prevent hypoxia
2. Impaired bed and physical mobility related to paralysis
INTERVENTIONS RATIONALE
Turning and positioning this prevents decubitus
every 2 hours ulcers
Passive ROM exercises at this prevents contractures
least twice daily
Padding may be placed this helps reduce the risk of
over bony prominences pressure ulcers
such as elbows and heels
Monitor intake and output, malnutrition and
note for malnutrition and dehydration increases the
dehydration risk of pressure ulcers