Nursing Dx

• Assess for concomitant pain/discomfort that may restrict/ limit respiratory effort.

NURSING PRIORITY NO. 2. To provide for relief of causative factors:
• Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress, or cyanosis.
• Suction airway as needed to clear secretions.
• Assist with bronchoscopy or chest tube insertion as indicated.
• Elevate HOB as appropriate to promote physiological/ psychological ease of maximal inspiration.
• Encourage slower/deeper respirations, use of pursed-lip technique, and so on to assist client in “taking control” of the situation.
• Have client breathe into a paper bag to correct hyperventilation.
• Maintain calm attitude while dealing with client and SO(s) to limit level of anxiety.
• Assist client in the use of relaxation techniques.
• Deal with fear/anxiety that may be present. (Refer to NDs Fear and/or Anxiety.)
• Encourage position of comfort. Reposition client frequently if immobility is a factor.
• Splint rib cage during deep-breathing exercises/cough if indicated.
• Medicate with analgesics as appropriate to promote deeper respiration and cough. (Refer to NDs acute Pain, or chronic Pain.)
• Encourage ambulation as individually indicated.
• Avoid overeating/gas-forming foods; may cause abdominal distention.
• Provide use of adjuncts, such as incentive spirometer, to facilitate deeper respiratory effort.
• Supervise use of respirator/diaphragmatic stimulator, rocking bed, apnea monitor, and so forth when neuromuscular impairment is present.
• Maintain emergency equipment in readily accessible location and include age/size appropriate ET/trach tubes (e.g., infant, child, adolescent, or adult).
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review etiology and possible coping behaviors.
• Teach conscious control of respiratory rate as appropriate.
• Maximize respiratory effort with good posture and effective use of accessory muscles.
• Assist client to learn breathing exercises: diaphragmatic, abdominal breathing, inspiratory resistive, and pursed-lip as indicated.
• Recommend energy conservation techniques and pacing of activities.
• Encourage adequate rest periods between activities to limit fatigue.
• Discuss relationship of smoking to respiratory function.
• Encourage client/SO(s) to develop a plan for smoking cessation. Provide appropriate referrals.
• Instruct in proper use and safety concerns for home oxygen therapy as indicated.
• Make referral to support groups/contact with individuals who have encountered similar problems.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Relevant history of problem.
• Respiratory pattern, breath sounds, use of accessory muscles.
• Laboratory values.
• Use of respiratory supports, ventilator settings, and so forth.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching, actions performed, and treatment regimen.
• Mastery of skills, level of independence.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs, including appropriate referrals and action taken, available resources.
• Specific referrals provided.