Nursing management
The nurse should monitor and assess the following:
- Changes in temperature and pulse.
- Amount, odor, and color of secretions.
- Frequency and severity of cough.
- Degree of tachypnea or shortness of breath.
- Changes in physical assessment findings (primarily assessed by inspecting and auscultating the chest)
- Changes in the chest x-ray findings
- In addition, it is important to assess the elderly patient for unusual behavior, altered mental status, dehydration, and excessive fatigue.
Nursing diagnosis:
Based on the assessment data, the patient's major nursing diagnoses may include:
- Ineffective airway clearance related to copious tracheobronchial secretions.
- Activity intolerance related to impaired respiratory function. Risk for deficient fluid volume related to fever and dyspnea.
- Imbalanced nutrition: less than body requirements.
- Deficient knowledge about the treatment regimen and preventive health measures.
Nursing Intervention:
- Isolation of the patient is necessary in the acute stage.
- Hand washing and cleanliness are important together with prevention of visitors with cold.
- Follow ABGs to determine oxygen need and response to oxygen therapy.
- Place patient in a fairly upright position to obtain greater lung expansion.
- Encourage increased warm fluid intake.
- Encourage breathing exercises and coughing exercise.
- Employ postural drainage.
- Oxygen therapy to loosen secretions and improve ventilation.
- Ascultate the chest frequently and monitor vital signs.
- Administer cough suppressants according physician order.
- Encourage bed rest during febrile period.
- Educate to avoid smoking
- Advise patient to keep up natural resistance with good nutrition and adequate rest.
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