About
Bacterial collection of fluid in the lobes of the lungs.
Assess
Lung sounds, airway, pulse-oximetry, vital signs, history of previous illness, use of accessory muscles with breathing, ease of respirations, dyspnea, color and character of sputum, sputum culture, pain, coughing.
Complications
Sepsis- systemic infection
Respiratory distress- requires intubation.
Impaired gas exchange- requires increasing O2 therapy and/ or intubation.
Diagnosis
- Ineffective airway clearance related to infectious process
- Impaired gas exchange related to infectious process in the lungs
- Activity intolerance related to difficulty in breathing, presence of infectious process
Goals
- Client will maintain a patent airway.
- Client will be able to demonstrate effective coughing and deep breathing exercises.
- Client will identify signs and symptoms to report to health care providers.
Interventions
- Monitor respirations, pulse oximetry, breathing pattern.
- Assess lung sounds, noting any increase in crackles or rhonchi.
- Monitor for signs and symptoms of impaired oxygenation including anxiety, restlessness, irritability, confusion, lethargy.
- Monitor sputum production and color, consistency; send for specimen as indicated.
- Initiate and teach client how to use an incentive spirometer at least ten times an hour while awake.
- Administer oxygen therapy as indicated.
- Administer medications, as prescribed by physician, including nebulizers and antibiotics.
- Administer IV fluids and oral fluids to maintain hydration.
- Teach client s/s to report to health care providers.
- Teach client about the medications he/ she is receiving and potential side-effects.
- Monitor for signs/ symptoms of complications.
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