Nursing Diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane damage.
Objective: effective gas exchange.
Expected outcomes:
- Demonstrated effective respiratory frequency.
- Improved gas exchange in the lung.
- Adaptive address causative factors.
Plan of action:
1. Provide a comfortable position, usually with the head of the bed elevated. Return to the affected side. Encourage clients to sit as much as possible.
R / Increase maximal inspiration, enhance ekpsnsi lung and ventilation on the side that does not hurt.
2. Observation of respiratory function, record the frequency of breathing, dyspnea or changes in vital signs.
R / Respiratory Distress and changes in vital signs may occur as a result of physiological stress and pain can indicate the occurrence syock or in connection with hypoxia.
3. Explain to the client that it was carried out to ensure safety.
R / knowledge of what is expected to reduce anxiety and develop client adherence to treatment plans.
4. Explain to the client about the etiology / precipitating factors or the presence of congested lungs collapse.
R / knowledge of what is expected to develop client adherence to treatment plans.
5. Keep calm behavior, help the patient to self-control circuitry using breathing more slowly and deeply.
R / Helping clients experience the physiological effects of hypoxia, which may be manifested as a fear / anxiety.
6. Collaboration with other health team:
By physicians, radiology and physiotherapy.
- Giving antibiotics.
- examination of sputum and sputum cultures.
- Consul-ray photo.