About
Alveolar collapse with or without infection, causing decreased oxygen in the blood.
Assess
Lung sounds, crackles, rhonchi, pulse oximetry, ease of respirations, respiratory effort, use of incentive spirometry, activity level, previous medical and drug history.
Complications
Respiratory distress- use appropriate precautions to promote adequate pulmonary toileting in the hospitalized client.
Pneumonia- administer prescribed antibiotics, monitor for a change in respiratory status.
Hypoxemia- monitor pulse oximetry, administer oxygen.
Diagnosis
- Ineffective breathing pattern related to scarring and thickening of lung tissue
- Impaired gas exchange related to altered capillary alveolar membrane
Goals
- The client will have clear lung sounds.
- The client will demonstrate proper use of an incentive spirometry.
Interventions
- Assess lung sounds, notify physician if increase in crackles, dyspnea, hypoxia, or other symptoms of respiratory distress.
- Ambulate client frequently to encourage deep inspiration.
- Encourage client to do incentive spirometry at least 10 times an hour.
- Encourage coughing and deep breathing frequently. If abdominal or thoracic incision, teach client splinting while doing pulmonary exercises.
- When initiating O2, monitor for an increase in crackles that may indicate atelectasis.
- Teach client how to do incentive spirometry.
- Monitor for signs/ symptoms of complications.
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