NURSING INTERVENTION

1. Regularly monitor the client’s respiratory rate and pattern, pulse

oximetry, ABG results, and manifestations of hypoxia or hypercapnia.
Report significant changes or a lack of response promptly.

RATIONALE: Prompt recognition of deteriorating respiratory function

can reduce potentially lethal outcomes.

2. Administer low-flow oxygen therapy (1 to 3 L/min on 24% to 31%

Fio2) as needed via nasal prongs or a high flow Venturi mask.

RATIONALE: Oxygen corrects existing hypoxemia. Excessive increase

in oxygen (55% to 70% Fio2) may diminish respiratory drive and
increase carbon dioxide retention further.

3. Assist the client into the high fowlers position.

RATIONALE: The upright position allows full lung expansion and

enhances enhances air exchange.

4. Teach patient to maintain adequate hydration by drinking at least 8 to

10 glasses of fluid per day (if not contraindicated) and increasing the
humidity of the ambient air.

RATIONALE: Hydration helps to thin secretions.

5. Teach and supervise effective coughing techniques.

RATIONALE: Proper coughing techniques conserve energy, reduce

airway collapse, and lessen client frustration.

6. Provide a quiet, calm environment.

RATIONALE: Reduction of external stimuli helps promote relaxation.

7. Assist the client in scheduling a gradual increase in daily activities and
exercises.

RATIONALE: Gradual increase in physical activity improve respiratory

and cardiac conditioning, thus improving activity tolerance.

7. Assist client with mouth care before meals and as needed.

RATIONALE: Coughing and sputum production may interfere appetite.

Mouth breathing dries mucous membranes.

8. Advise the client to eat small, frequent meals that are high in protein
and calories.

RATIONALE: Large meals may create an excessive feelin of fullness

that may make breathing uncomfortable and difficult. High protein and
calorie levels are needed to maintain nutritional status in light of the
increased work of breathing.

9. Advise patient to avoid gas-producing foods, such as beans and

cabbage.

RATIONALE: Gas-forming foods may cause abdominal bloating and

distention and thus impair ventilation.

10.Suggest measures that may facilitate sexual activity.

RATIONALE: Such measures can reduce physical exertion and

maximize available oxygen levels.

11.Teach the client to wash his/her hands after contact with potentially
infectious material.

RATIONALE: Handwashing is the primary defense the spread of

infection.
12.Encourage the client to obtain a flu vaccination yearly and a
pneumococcal vaccination.

RATIONALE: Vaccination provides immunity for infections.

13.Advise patient to avoid conditions that increase oxygen demand, such
as smoking, temperature extremes, excess weight and stress.

RATIONALE: These factors increase increase peripheral vascular

resistance, which increases cardiac workload and oxygen requirements.

14.Teach the client and family how to care for and clean respiratory
equipment used at home.

RATIONALE: Water in respiratory equipment is a common source of

bacterial growth.

15.Teach the client and family the manifestations of pulmonary

infections ( change in color or volume of sputum, fever, chills,
malaise, productive cough, confusion, increased dyspnea), self-care,
and when to call the physician.

RATIONALE: Early recognition of manifestations can lead to a rapid

diagnosis. Self-care with pre-planned interventions should be understood.
Notification of the physician can provide for early treatment.