Related to: Inflammatory process.
Defining Characteristics: (Specify: shortness of breath, tachypnea, fremitus.) Related to: Decreased lung expansion.
Defining Characteristics: (Specify: apnea, dyspnea, respiratory depth changes.) Related to: Tracheobronchial obstruction.
Defining Characteristics: (Specify: dyspnea, head bobbing in infant, drooling, tachypnea, abnormal arterial blood gases, cyanosis (skin, circumoral, mucous membranes), nasal flaring, respiratory depth changes, use of accessory muscles and retractions, altered chest excursion, prolonged expiratory phase, grunting, apnea during sleep, anxiety, air hunger, sitting up with mouth open to breathe, stridor on inspiration, persistent cough, throat edema.)
Goal: Infant/child will experience an effective breathing pattern by (date/time to evaluate). Outcome Criteria
V Return of respiratory status to baseline parameters for pattern rate, depth, and ease (specify).
V Effective breathing effort and improved chest expansion. NOC: Respiratory Status: Airway Patency, Ventilation
Assess respirations for rate (count for Reveals rate and type of respirations one full minute), pattern, depth, and (baselines or deviations) that are ease; presence of tachypnea related to age and size of the
(specify), dyspnea and use of infant/child and presence of anxiety accessory muscles and retractions and disease processes, changes in
(intercostal, subcostal, substernal, patterns indicate the acuteness of a suprasternal), nasal flaring; note condition and the respiratory expiratory phase, chest expansion, periods of apnea, head bobbing in infant during sleep.
Assess configuration of chest by palpation; auscultate for breath sounds that indicate a movement restriction (absent or diminished, crackles or rhonchi).
Assess skin for pallor or cyanosis, distribution and duration of cyanosis (nail beds, skin, mucous membranes, circumoral).
Assess for cough, pain when coughing, characteristics of cough and sputum, ability to mobilize and bring up secretions when amounts increase.
Position with head elevated at least 30° or seated upright with head on pillows; position on side if more comfortable; tripod position for the child with epiglottitis; avoid tight clothing or bedding; for child with low muscle tone, use pillows and/or padding to maintain positioning.
Perform deep breathing exercises and upper body exercises (isometric).
Assess child's pain and administer analgesics as prescribed (specify drug, dose, route, and time); use a pain assessment tool appropriate to the child's age (specify) and developmental level; assess and record child's response to pain control measures; provide age-appropriate diversional activities as tolerated (specify).
Pace activities and exercises, and allow for rest periods and energy conservation.
function that result from infection and obstruction; retractions that become severe are responses to a decrease in intrathoracic pressure that may extend to suprasternal area if lung consolidation is severe, nasal flaring occurs as the work of breathing increases, head bobbing occurs with dyspnea in infants.
Reveals an increased anteroposterior ratio common in children with chronic respiratory disease that results from hyperexpansion of the airways.
Reveals presence of hypoxemia causing cyanosis from an uneven distribution of gases and blood in the lungs, and alveolar hypoventilation caused by airway obstruction, weakness of muscles used in respirations.
Cough is an indication of a respiratory condition and if excessive may cause chest pain and interfere with respirations, accumulation of mucus in airways affects respiration if obstruction is present.
Facilitates chest expansion and respiratory efficiency by reducing pressure of abdominal organs on diaphragm; position of comfort is age-related and dependent on degree of dyspnea.
Strengthens intercostal and abdominal muscles, and diaphragm, which enhances breathing and prolongs expiratory phase.
Promotes improved oxygenation.
Prevents changes in respiratory pattern brought about from exertion and fatigue.
Monitor blood gas levels and provide supplemental oxygen via hood, tent, cannula, or face mask as needed if hypoxia results from inadequate breathing pattern and ventilation; if an infant is apneic, provide access at bedside at all times.
Administer bronchodilators via oral, subcutaneous, or aerosol therapy; antibiotics, or sedatives (cautiously) via oral therapy if respiratory efficiency is not reduced; antiasthmatics and steroids via oral or aerosol therapy as ordered (specify).
Assess family's responses to child's illness and/or hospitalization; utilize the principles of family-centered caregiving, which encourages the parents to participate in their child's illness within their comfort level.
Teach parents and child in handwashing and when to perform; disposal of tissues; covering mouth and nose when coughing to avoid those with respiratory infections.
Demonstrate and instruct to parents and child in possible positions for comfort and ventilation during activities and sleep.
Inform parents and child of activity restrictions and to avoid any activities beyond tolerance and energy level.
Instruct child in relaxation exercises, quiet play, and controlled breathing.
Inform parents and child to avoid allergens, changes in environmental temperatures, humidity, and pollutants, effect of pets, dust, dirty filters, plant odors, and other irritants in the home.
Teach parents about oxygen administration (correct rate and method specify) and safety measures (fire prevention).
Instruct and demonstrate medication regimen to parents (and older child) and include route, dosage, time, action, what to expect, and how to
Maintains oxygen level in blood to maintain tissue and organ function, amount and type of oxygen administration dependent on hypoxia and changes in mentation.
Relieves bronchospasms that affect respirations (tachypnea, rhonchi), prevents or treats infection, promotes rest and reduces anxiety to enhance breathing; prevents asthmatic attack and reinforces body defenses against allergic reactions (action of drug).
Parents know their child's behaviors, temperament, and reactions to previous illnesses and treatments better than the health care professionals; utilizing the parent's knowledge will promote understanding and improved caregiving.
Prevents transmission of microorganisms to child from inanimate objects or airborne droplets.
Facilitates ease of breathing.
Reduces potential dyspnea and fatigue.
Reduces anxiety in older child which increases respiratory rate. Prevents responses that change respiratory pattern.
Supplies oxygen when needed in a correct and safe manner.
Ensures accurate and safe administration for medications for optimal effect.
administer according to form prescribed (specify).
Teach parents to avoid giving child over-the-counter medications unless advised by physician.
Instruct parents in disinfection, care of reusable supplies, and care of equipment used to administer medications.
(Teach and demonstrate use of apnea monitor to parents (application, setting, alarms, electric source) and how to perform cardiopulmonary resuscitation on infant if needed).
Prevents any undesirable interactions with prescribed drugs.
Reduces potential for infection and preserves equipment and supplies for long-term use.
Provides alert system for parents to monitor changes in respirations and heart rate of infant with apnea episodes.
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