Nursing process in patients with Impaired Respiratory Function using measures ranging from assessment, nursing diagnosis, intervention, implementation and evaluation, thus enabling nursing care provided to clients can be optimized.
Assessment
General Assessment of the Respiratory System
The assessment process should be highly individualized nursing (according to the client's problems and needs of the moment). In reviewing the client's respiratory status, the nurse can conduct an interview and a physical examination to maximize the data collected without having to add client respiratory distress. Because the body is dependent on the respiratory system contain important aspect in evaluating the health of the client. Respiratory system primarily serves to maintain the exchange of oxygen and carbon dioxide in the lungs and tissues as well as to regulate acid-base balance, any change in the system will be used effects other systems in the body. In respiratory disease, pulmonary status change occurs slowly, allowing the client to adapt to hypoxia. However, changes such as pneumothorax aspiration, hypoxia that occurs suddenly and the body does not have time to adapt, so as to cause death.
Health History
Health history begins with collecting data on biography, which includes name, age, gender, and the client's life situation. Demographic data are usually recorded on the assessment form which have hospitals or clinics. Note the biological age of the client and compare the performances. Does the client seem appropriate for age, disorders such as lung cancer and chronic lung disease, the client looks older than age. Respiratory history contains information about the client's current condition and previous respiratory problems. Interview clients and families and focus it on the main clinical manifestations of the complaint, the events that led to the current state, past medical history, family history, psychosocial history. Share your questions with a simple, using short sentences that are easy to understand. Where appropriate repeat questions to clarify any questions that have been understandable. Collect a complete history of respiratory conditions conformed to the client.
Main complaint
The main complaint was collected to establish priority nursing interventions, and to assess understanding of the client's current health condition. Common complaints include dipsnea respiratory diseases, cough, sputum formation, hemoptysis, wheezing and chest pain. Focus on manifestations and prioritize questions to get an analysis of symptoms.
Past Medical History
Past medical history provides information about the client and family. Assess the client's clinical conditions such as cough, dyspnea, sputum and wheezing formation, because this condition gives hints about a new problem. In addition to collecting data on childhood immunization, ask the client about the incidence of tuberculosis, influenza, asthma, pneumonia and upper respiratory infection frequency after lower respiratory tract infections, fakator examine factors that affect the baby at the time such as cystic fibrosis, premature birth, the problems associated with the disorder obstructive pulmonary disease, restrictive. Ask clients whether they have been admitted to the hospital, ask when it happened, and obtained medical treatment when it's time. Get information about injuries nose mouth, throat or chest before (such as blunt trauma, fractures of the ribs, thoracic trauma). And important information about free drugs ever consumed.
Psychosocial History
Get information about the psychosocial aspects of client which includes occupation, geographical location, exercise habits, nutrition. Identify all environmental agents that may affect the client, and the work environment and habits.
Ask about the conditions of life of the client, who lives one house number, review the environmental hazards in crowded conditions, and poor circulation. Gather how long smoking history, and how the number of cigarettes consumed , also ask about the use of alcohol, lung ciliary movement is slowed by alcohol so it will reduce the clearance of mucus from the lungs. Ask if client activity tolerance decreased or stabilized, ask the client to describe how to walk, light housework that can be tolerated by the client or vice versa. Maintain a nutritious diet for clients with chronic respiratory disease. Chronic diseases that result in decreased lung capacity lungs work harder. Addition workload requires high calorie and nutrition and if not met will cause weight loss. Clients become secondary to medication anorexia and fatigue. Assess nutrient inputs during the last 24 hours, ask the client to remember the pattern of nutrient inputs during the last week.
Physical Assessment
Physical assessment is done after collecting medical history, use techniques of inspection, palpation, percussion, auscultation. The success of the examination requires nurses to master the posterior thoracic landmarks, lateral, anterior. Use these landmarks to locate under the thoracic organs, especially the lobe of the lung, heart and major blood vessels. Compare one side to the other. Palpation, percussion, auscultation performed backward from the front or from the side of the chest to the other side of the thorax, so that the results obtained are continuous with the other parts to make a comparison. Conditions and skin color observed during the inspection (pale, blue, red). Assess the client's level of awareness and orient the client during the client checks to determine the adequacy of gas exchange.
Nursing Diagnosis
1. Impaired gas exchange related to decreased lung expansion, the presence of pulmonary secretions, inadequate oxygen intake.
2. Ineffective Airway Clearance related to impaired cough, incision pain, decreased level of consciousness.
3. Ineffective Breathing Pattern related to immobilization, depression of ventilation, use of narcotics, neuromuscular damage, airway obstruction.
4. Decreased cardiac output related to irregular heart rhythms, rapid heartbeat.
5. Risk for infection related to static lung secretions.
6. Activity Intolerance which relate to: weakness, inadequate nutrition, fatigue.
Planning
Clients who suffered damage oxygenation, requiring nursing care plan is intended to meet the needs of the actual oxygenation and any potential client. Nurses identify specific end result of care provided. The plan includes one or more client-centered targets the following:
- Maintain airway patency.
- Maintain and sustain and improve lung expansion.
- Capable of removing the pulmonary excretion.
- Achieve an increase in activity tolerance.
- Maintained or increased tissue oxygenation.
- Cardiopulmonary function improved and maintained.
Implementation
Nursing interventions to improve oxygenation and maintain the domain covered by the nursing administration and monitoring therapeutic interventions and programs. This includes independent nursing actions such as behavioral health promotion and prevention, setting position, coughing techniques, and collaborative interventions such as oxygen therapy, lung inflation techniques, hydration, chest physiotherapy, and medicine.
