Medical-surgical Nursing Demystified

CHAPTER 2 Respiratory System^117

results are returned. Patients may need bronchodilators to help open the
airways.

• Administer oxygen as needed.


• For bacterial infections, administer antibiotics such as macrolides (azithro-
  mycin, clarithromycin), fluoroquinolones (levofloxacin, moxifloxacin),
  beta-lactams (amoxicillin/clavulanate, cefotaxime, ceftriaxone, cefuroxime
  axetil, cefpodoxime, ampicillin/sulbactam), or ketolide (telithromycin).


• Administer antipyretics when fever >101 for patient comfort:
  
  
  • acetaminophen, ibuprofen
  
  
  
  


• Administer brochodilators to keep airways open, enhance airflow if needed:
  
  
  • albuterol, metaproterenol, levalbuterol via nebulizer or metered dose
    inhaler
  
  
  
  


• Increase fluid intake to help loosen secretions and prevent dehydration.


• Instruct the patient on how to use the incentive spirometer to encourage deep
  breathing; monitor progress.

NURSING DIAGNOSES

• Risk for aspiration


• Impaired ventilation


• Ineffective airway clearance

NURSING INTERVENTION

• Monitor respiration for rate, effort, use of accessory muscles, skin color, and
  breath sounds.


• Record fluid intake and output for differences, signs of dehydration.


• Record sputum characteristics for changes in color, amount, and consistency.


• Properly dispose of sputum.


• Explain to the patient:
  
  
  • Take adequate fluids—3 liters per day—to prevent excess fluid loss through
    the respiratory system with exhalation.
  
  
  • Use of incentive spirometer.