Section IV. NURSING IMPLICATIONS BY BODY SYSTEMS OF A
4-13. RESPIRATORY SYSTEM
Postoperative nursing intervention to meet respiratory needs is chiefly designed
to prevent respiratory complication. Nursing actions include checking the patient's
respiratory rate, depth, and rhythm as ordered or according to local policy or whenever
vital signs are taken. Being alert to signs of respiratory problems cannot be over
emphasized. Measures for encouraging lung expansion and exchange of gas are given
Reteach the patient coughing and deep breathing exercises (refer to
Lesson 1, paras 1-5a(2) and (3)). Coughing is encouraged to dislodge mucous plugs.
Deep breathing helps to maximize voluntary lung expansion. Record the procedure and
report significant observations to the Charge Nurse. Include the time of procedure,
sputum (if present -- color, odor, amount), and patient's tolerance.
Turn the patient as ordered (refer to Lesson 1, para 1-5a(1)). Turning the
patient allows alternating maximum expansion of the uppermost lung.
Ambulate the patient as ordered. If the patient cannot ambulate,
periodically assist him to a sitting position in bed if allowed. This position permits the
greatest lung expansion. Ambulation promotes deep breathing.
Position the patient in a Fowler's position to facilitate lung expansion, if
4-14. CARDIOVASCULAR SYSTEM
Nursing measures to meet the patient's circulatory needs are provided to prevent
Reteach lower extremity exercises while the patient is on bedrest (refer to
Lesson 1, para 1-5a(4)).
Ambulate the patient, as ordered.
Provide physical support for first attempts.
Have patient dangle feet at bedside before ambulation.
Monitor patient's blood pressure while he dangles.