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R: Increasing lethargy,
confusion, restlessness,
and/or irritability can be
initial signs of cerebral
hypoxia. Lethargy and
somnolence are late
signs.
R: Increased work of
breathing can lead to
tachycardia and
hypertension. Retained
secretions or atelectasis
may be a sign of an
existing infection or
inflammatory process
manifested by a fever or
increased temperature.
6. Assess for
abdominal or
thoracic pain.
8. Perform
nasotracheal
suctioning as
necessary,
especially if cough is
ineffective.
R: Suctioning is needed
when patients are
unable to cough out
secretions properly due
to weakness, thick
mucus plugs, or
excessive or tenacious
mucus production.
9. Give medications as
prescribed, such as
antibiotics, mucolytic
agents,
bronchodilators,
expectorants, noting
effectiveness and
side effects.
R: A variety of
medications are
prepared to manage
specific problems. Most
promote clearance of
airway secretions and
may reduce airway
resistance.
R: Chest physical
therapy helps mobilize
bronchial secretions; it
should be used only
when prescribed
because it can cause
harm if patient has
underlying conditions
such as cardiac disease
or increased intracranial
pressure.
R: Readiness for an
emergency helps
prevent further
complications.
Intubation may be
needed to facilitate
removal of tenacious
and copious amounts of
secretions and provide
source for augmenting
oxygenation.
Reference:
Carpenito-Moyet,L. (2012).
Nursing diagnosis:
Application to clinical
practice (14th ed.).
Philadelphia, PA:
Lippincott, Williams, &
Williams.