Co||ege of Nurs|ng

S||||man Un|vers|ty
Dumaguete C|ty

NUkSING CAkL LAN
Cues and Lv|dences D|agnos|s Cb[ect|ves Intervent|ons kat|ona|e

Cb[ect|ve
O Appears cyanoLlc faLlgue
and ln resplraLory
dlsLress
O esL xray revealed
pneumonla ln rlgL lower
lobe
O saLuraLlon80
O AdmlLLed Lo L8 for
dyspnea
O 9resence of rales
O A8G resu|t
pn
CC2 0mmPg
nC0313 mLq/L

Ineffect|ve a|rway
c|earance re|ated to
|ncreased sputum
product|on secondary to
pneumon|a

W|th|n my care the c||ent w||| be
ab|e to man|fest decrease s|gns
and symptoms of |neffect|ve
a|rway c|earance as ev|denced by

O 9aLlenL wlll ave a paLenL
alrway
O oesn'L appear cyanoLlc
faLlgue and ln resplraLory
dlsLress
O Absence of advenLlLlous
sounds (8ales)
O emonsLraLe beavlors Lo
lmprove alrway clearance
O saLuraLlon ln normal
range (93100)
O A8G kesu|ts |n norma|
range
pP33
33 mmPg
P0 mLq/L
O Absence of dyspnea

O Assess raLe/depL of
resplraLlons and cesL
movemenL




O AusculLaLe lung flelds for
advenLlLlous breaL
sounds eg crackles
weezes



O LlevaLe ead of bed
cange poslLlon
frequenLly

O @eac paLlenL ow Lo
coug effecLlvely and do
deep breaLlng exerclses

O Lncourage Le cllenL Lo
lncrease fluld lnLake

O @acypnea sallow
resplraLlons and asymmeLrlc
cesL movemenL are
frequenLly presenL because
of dlscomforL of movlng
cesL wall and/or fluld ln
lung
O rackles roncl and
weezes are eard on
lnsplraLlon and/or explraLlon
ln response Lo fluld
accumulaLlon Llck
secreLlons and alrway
spasm/obsLrucLlon
O 9romoLes lung expanslon
because lL can elp moblllze
and expecLoraLe secreLlons

O ouglng and deep breaLlng
elps loosens secreLlons for
beLLer expecLoraLlon

O PydraLlon elps lossens
secreLlons
Co||ege of Nurs|ng
S||||man Un|vers|ty
Dumaguete C|ty

NUkSING CAkL LAN
Cues and ev|dences D|agnos|s Cb[ect|ves Intervent|ons kat|ona|e

Cb[ect|ve
O 9aLlenL as edema ln
boL exLremlLles
O ncreased abdomlnal
glrL and palpable llver
and spleen noLed
O AssessmenL revealed
asclLes
O 0 saLuraLlon 80


I|u|d vo|ume excess re|ated to
th|rd space f|u|d sh|ft
secondary to asc|tes

W|th|n my care c||ent w|||
man|fest reduced s|gns and
symptoms of f|u|d vo|ume
excess as ev|denced by

O Absence of edema ln
boL exLremlLles
O ecrease abdomlnal
glrL
O Absence of palpable
llver and spleen
O Absence of abdomlnal
dlsLenLlon
O saLuraLlon ln
normal range (93
100)
O emonsLraLe
beavlors Lo monlLor
fluld sLaLus and
reduce recurrence of
fluld excess




O ,onlLor lnLake and
ouLpuL


O ,easure abdomlnal
glrL

O Lncourage cange of
poslLlon
O 8esLrlcL fluld lnLake

O 9alpaLe Abdomen noLe
reporLs of rlgL upper
quadranL paln /
Lenderness




O Jelg cllenL dally



O @o reveal canges LaL sould
be made ln dleLary lnLake
mlnlmlze compllcaLlon
asclLes
O lndlcaLe lncreaslng or
decreaslng fluld
reLenLlon/edema
O 9romoLe recumbency reduced
dluresls
O @o prevenL furLer fluld excess

O Advanclng Pl leads Lo
venous congesLlon resulLlng
ln abdomlnal dlsLenslon
epaLomegaly and paln @ls
can alLer llver funcLlon and
lmpalr/ prolong drug
meLabollsm

O ody welgL ls a senslLlve
lndlcaLor of fluld balance and
lncrease lndlcaLes fluld volume
excess

Co||ege of Nurs|ng
S||||man Un|vers|ty
Dumaguete C|ty

NUkSING CAkL LAN
Cues and Lv|dences D|agnos|s Cb[ect|ves Intervent|ons kat|ona|e

Cb[ect|ve
O Appears cyanoLlc faLlgue
and ln resplraLory
dlsLress
O AdmlLLed Lo L8 for
dyspnea
O saLuraLlon 80
O A8G resu|ts
pn
C020 mmPg
nC0313 mLq/L
O ncrease abdomlnal glrlL
O 9alpable llver and spleen


Ineffect|ve breath|ng
pattern re|ated to |ncreased
abdom|na| pressure on the
d|aphragm secondary to
asc|tes

W|th|n my care c||ent w|||
man|fest reduced s|gns and
symptoms of |neffect|ve
breath|ng pattern as ev|denced
by

O Absence of cyanosls
faLlgue and resplraLory
dlsLress
O Absence of dyspnea
O saLuraLlon ln 93
100
O A8G resu|ts |n norma|
range
pn33
C0233 mmPg
nC03 mLq/L
O ecrease abdomlnal
glrL
O Absence of palpable
llver and spleen



O @eac paLlenL
dlaparagmaLlc and
pursed llp breaLlng

O Lncourage alLernaLlng
acLlvlLy wlL resL perlods

O 9oslLlon cllenL ln lg
fowlers poslLlon
O ,onlLor ls/er
resplraLory sLaLus
O Ask cllenL Lo coug and
Lake a deep breaL
ourly
O LlevaLe ead of Le bed

O llenL may need Lo use
lncenLlve splromeLry or
recelved ulLrasound
LreaLmenLs
O 8esLrlcL Loo muc fluld
lnLake

O Pelps paLlenL prolong
explraLlon Llme and decrease
alr Lrapplng 9aLlenL wlll breaL
more effecLlvely and efflclenLly
O 9aclng acLlvlLles permlLs
paLlenL Lo perform acLlvlLles
wlLouL excesslve dlsLress
O @o faclllLaLe breaLlng

O @o know lf unwanLed
compllcaLlons may occur
O @o malnLaln adequaLe
resplraLory funcLlon

O @o promoLe lung expanslon and
faclllLaLe effecLlve breaLlng
O @o brlng up resplraLory
secreLlon and Lo faclllLaLe
effecLlve breaLlng

O o as noL Lo promoLe furLer
lncrease ln lnLraabdomlnal
pressure