- Administer oxygen as ordered to maintain Spo2 above 90%.
- Notify the physician of A.B.'s symptoms and vital sign changes.
- Monitor and document A.B.'s respiratory status every 1-2 hours.
- Assist with chest physiotherapy to promote airway clearance.
- Encourage deep breathing and coughing exercises to improve ventilation.
- Administering oxygen will increase oxygen saturation and prevent hypoxemia.
- Notifying the physician will allow prompt interventions and prevent complications.
- Monitoring respiratory status will detect changes early and guide appropriate interventions.
- Chest physiotherapy will help mobilize secretions and improve gas exchange.
- Deep breathing and coughing exercises will prevent atelectasis and improve lung function.
- Objective and subjective data:
- Objective data: Spo2 of 95% on oxygen at 2 L per nasal cannula, diminished lung sounds in the right lower lobe, chest drainage system attached to suction at 20 mm Hg, air leak present, residual pleural effusion on morning chest x-ray.
- Subjective data: A.B.'s report of feeling short of breath.
- Oxygen administration maintained Spo2 above 90%.
- Physician notified promptly and interventions initiated.
- Respiratory status monitored and documented every 1-2 hours.
- Chest physiotherapy and deep breathing and coughing exercises implemented and tolerated.
- A.B.'s symptoms relieved and respiratory status improved.
- Maintain Spo2 above 90%.
- Prevent complications related to pleural effusion and pneumonia.
- Improve A.B.'s respiratory status.
- Relieve A.B.'s symptoms of shortness of breath, pain, weakness, and cough.
- Facilitate A.B.'s recovery and discharge from the hospital.
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