NURSING DIAGNOSIS AND INTERVENTIONS

DIAGNOSIS
1. Ineffective breathing pattern related to rapidly
progressive weakness and impending respiratory
failure
INTERVENTIONS RATIONALE
Maximize respiratory incentive spriromertry
function with incentive aids in the lung
spirometry expansion to prevent
lung collapse or
atelectasis
Perform chest chest physiotherapy
physiotherapy (e.g. therapy helps in
vibration and cupping) immobilizing and proper
drainage of secretions
Perform deep breathing strengthens respiratory
and cupping exercises muscles, facilitates full
lung expansion and
coughing out secretions
Administer oxygen
therapy to supply enough oxygen
to body tissues and
prevent hypoxia
2. Impaired bed and physical mobility related to paralysis
INTERVENTIONS
Turning and positioning
every 2 hours
Passive ROM exercises at
least twice daily
Padding may be placed
over bony prominences
such as elbows and heels
Monitor intake and output,
note for malnutrition and
dehydration
RATIONALE
this prevents decubitus
ulcers
this prevents contractures
this helps reduce the risk of
pressure ulcers
malnutrition and
dehydration increases the
risk of pressure ulcers