Medical-surgical Nursing Demystified

CHAPTER 2 Respiratory System^127

NURSING DIAGNOSES

• Ineffective breathing pattern


• Ineffective airway clearance


• Anxiety

NURSING INTERVENTION

• Monitor respiratory status for rate, effort, use of accessory muscles, sputum
  production, and breath sounds.


• Monitor pulse oximetry to check oxygen saturation levels.


• Monitor sputum for changes in color and amount.


• Monitor vital signs for changes.


• Place patient in high Fowler’s or semi-Fowler’s position on bedrest to ease
  respiratory effort by allowing optimal diaphragmatic excursion.


• Monitor ventilator settings if appropriate.


• Change patient position every 2 hours to decrease chance of skin breakdown.


• Monitor intake and output of fluids to check for balance.


• Explain to the patient:
  
  
  • The importance of doing coughing and deep-breathing exercises to fully
    expand lungs and enhance the expelling of mucous.
  
  
  • How to identify the signs of respiratory distress.
  
  
  
  

Pulmonary Embolism

WHAT WENT WRONG?

Blood flow is obstructed in the lungs caused by thrombus (blood clot), air, or fat
emboli that become stuck in an artery, causing impaired gas exchange. Patients
may be predisposed to clot formation, have pooling of blood, or damage to ves-
sel walls, or take certain medications that increase the risk of thrombus formation.
Thrombus are commonly found in vessels in lower extremities. When a throm-
bus loosens and travels in the peripheral circulation, it is called an embolus. The
embolus travels through the right side of the heart and is sent to the lungs where

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