Cough with phlegm or mucous

Fever, sweating, chills

Shortness of Breath

Sharp or stabbing chest pain;Subjective

Loss of Appetite

Blood tests

Chest X-Ray

Pulse Oximetry

Sputum Test

Antibiotics

Cough Medicine

Fever reducers/pain medications

Rapidly rising fever

Rapid bounding pulse

Tachypnea

Purulent Sputum

Pleuritic Chest Pain

RR: 28 breathes/minute

Pulse: 100 beats/minute

BP: 140/90 mm Hg

Skin warm, dry, pale pink with brisk capillary refill.

No edema

Pt on nasal cannula at 6L/minute

Decreased oral intake

DNR

Provide oral care after coughing, respiratory treatments, before meals. Coughing and secretions might create a taste in the mouth which can interfere with appetite.

Assess food intake and provide supplements if intake is insufficient to meet caloric needs. Supplements can provide extra calories and nutrients.

Encourage liberal fluid intake. Pt presenting with fever and/or dyspnea can lose excess body fluids through the skin and lungs. Double check for contraindications such as heart failure or kidney disease where there might be a fluid restriction.

Weigh daily. Monitor progress so the plan can adapt/change as needed. Daily gain or loss in excess of 1 lb are often due to fluid balance alterations. Slower gains or losses may be due to nutritional imbalance.

Teach client effective techniques for coughing. Increase clearance of exudates.

Assist with postural drainage. Promote exudate movement through gravity, percussion, vibrations of the chest.

Humidify inspired oxygen and encourage oral fluid intake. Promotes liquifaction of pulmonary secretions which encourages exudates to come up.

Encourage client to lay on unaffected side while in bed. Might assist with ventilation and perfusion.

When assessing for dyspnea, do so during rest and during activities; eating, talking, moving around. Pt might become dyspneic during minimal activity.

Decreased effort at breathing

Pt will report dyspnea has been relieved

Respiratory and heart rates within normal range

Continuous weight monitoring to ensure intake is meeting pt needs

Sub Topic