Nursing Interventions:
1.
Frequently assess respiratory status including rate,
depth, effort, lung sound and SPO2 at least every 2-4 hours.
2.
Assess the mental status of the client (changes in
orientation and behavior). Assess for increased hypoxia.
3.
Analyze lab work including ABG’s and hemoglobin and
hematocrit.
4.
Position the patient in high fowler’s position and
collaborate with the health-care team regarding prone positioning.
5.
Administered oxygen as ordered by the doctor.
6.
Provide teaching regarding respiratory exercises.
7.
Maintain bed rest.
8.
Turn every 2 hours on (odd/even) hour.
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Rationale:
1.
Impaired
ventilation affects gas exchange and worsens hypoxemia (Tachypnea, dyspnea).
SPO2 can be used as a non-invasive method to monitors oxygen saturation. (Cox’s
Clinical pg: 294)
2.
Restlessness is an early sign of hypoxia
.Hypoxemia often causes confusion and agitation. (Cox’s Clinical pg: 350)
3.
Will provide
integral information to determine deficits in capacity and effect of oxygen
delivery. (Cox’s Clinical pg: 347)
4.
Facilities chest
expansion and promotes gas exchange and with alveolar recruitment. (Cox’s
Clinical pg: 347)
5.
To improve
oxygenation.
6.
Promotes alveolar
open. (Cox’s Clinical pg 347)
7.
Bed rest reduces
metabolic demands for oxygen. (Cox’s Clinical pg: 347
8.
Position changes
modify ventilation- perfusion relationships and enhance gas exchange. (Cox’s
Clinical pg: 347)__________________________
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Client Response:
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