NURSING CARE PLAN

Nursing Diagnosis Subjective Impaired gas Cues: exchange related to Upon arrival decreased at the ventilation and emergency mucus plugs room, the client verbalized that: Hindi ako makahinga. Bakit ba ang tagal naman ng mga doctor? Dalawang taon na akong may Emphysema, madalas hirap ako huminga pero mas matindi ngayon. When asked by the Cues Analysis Inflammation of the bronchial walls causes them to thicken. This thickening, together with excessive mucus, blocks the airways and hinders gas exchange. Reference: MedicalSurgical Nursing: A Psychophysiolo gic Approach, 4th Ed., Palandri, et. al, pp. 151-152 . Goals and Objectives After 4 hours of nursing intervention, the client will be able to maintain adequate gas exchange as evidenced by stable blood gas values and normal respirations. Objectives: 1) The client will be able to maintain patent airway and normal breathing patterns. Interventions Rationale Evaluation

1) Regularly monitor respiratory rate and pattern, ABG results, and signs of hypoxia or hypercapnia. Report significant changes promptly.

Prompt recognition of deteriorating respiratory function can reduce potentially lethal outcomes.

2) Administer

low-flow oxygen therapy (1-3 L/min 24-31% FIO2) as needed via nasal prongs or high-flow venture mask (24-41% FIO2).

Reference: Medical-Surgical Nursing, Luckmann, pp. Efficiency 1997 Were the resources available to the nurse Oxygen corrects existing nd the client hypoxemia. Excessive maximized? increases in oxygen (55- _Yes _No 70% FIO2) may diminish Why? respiratory drive and further increase carbon Appropriateness dioxide retention. Were interventions

Adequacy Was the client able to maintain patent airway and normal breathing patterns? _Yes _No Why?

physician on how frequent he experiences dyspnea, the client answered, Always. Objective Cues: - 67% oxygen saturatio n - Dyspn ea - Shortn ess of breath - Nasal flaring - Produc tive cough - Client looks fatigued when breathin g

appropriate to client Reference: situation? Medical-Surgical _Yes _No Nursing, Luckmann, pp. Why? 1997 Acceptability 3) Assist client into high The upright position Were the Fowlers position. allows full lung interventions excursion and enhances acceptable to the air exchange. client and significant others? Reference: _Yes _No Medical-Surgical Why? Nursing, Luckmann, pp. 4) Administer 1997 Adequacy bronchodilators as Were the ordered. Monitor for side Bronchiodilators relax interventions effects. bronchial smooth adequate to address muscle, facilitating the clients needs and airflow. Common side problem? effects include tremor, _Yes _No tachycardia and other Why? cardiac dysrhythmias. Reference: Medical-Surgical 5) Use caution when Nursing, Luckmann, pp. administering narcotics, 1997 sedatives and tranquilizers. These medications are respiratory depressants and can further impair ventilation.

- Hyperv entilation - Presen ce of barrel chest - Raised acromion processe s and use of accessor y muscles for breathin g

2) The client will be able to demonstrate modified breathing techniques that facilitate ventilator capacity.

Reference: Medical-Surgical Adequacy 1) Assess the ventilation: Nursing, Luckmann, et. Was the client able to a) Weakness and tiring in al, pp. 1997 maintain patent relation to attempts to airway and normal breathe. Information is gained breathing patterns? b) Breathing pattern, about the effectiveness _Yes _No rate, rhythm, and of the treatment plan Why? depth; chest and the need for its expansion, presence modification. Efficiency of respiratory distress Were the resources (shortness of breath, Reference: available to the nurse wheezing or dyspnea), Medical-Surgical nd the client nasal flaring, pursed- Nursing: A Nursing maximized? lip breathing, Process Approach, _Yes _No prolonged expiratory Ignatavicius, et. al, 580 Why? phase, use of accessory muscles. Appropriateness Were interventions 2) Instruct client in appropriate to client techniques of breathing situation? such as: _Yes _No a) Pursed-lip breathing Breathing techniques Why? b) Diaphragmatic facilitate exhalation of breathing stagnant, trapped air Acceptability c) Relaxation therapy and are beneficial during Were the d) Coughing and deep dyspneic episodes. interventions breathing acceptable to the Reference: client and significant Medical-Surgical others? Nursing: A Nursing _Yes _No Process Approach, Why?

3) Assist client in maintaining proper positioning during dyspneic episodes: a) Sitiing up and leaning on over-bed table (orthopneic position) b) Sitting up and resting with elbows on knees c) Standing and leaning against wall

Ignatavicius, et. al, 580 Adequacy Use of accessory Were the muscles is facilitated by interventions supporting arms and adequate to address shoulders, and thoracic the clients needs and cavity is enlarged for problem? increased lung _Yes _No expansion. Why?

Reference: Medical-Surgical Nursing: A Nursing 4) Maximize the effect of Process Approach, medical interventions by Ignatavicius, et. al, 580 proper sequencing of respiratory treatments Work of breathing is and by judicious use of reduced by decreasing bronchodilators and inflammatory processes steroids (IV, oral, or and through inhaled). bronchodilation. Reference: Medical-Surgical Nursing: A Nursing 5) Assess the quality and Process Approach, quantity of sputum: color, Ignatavicius, et. al, 580 consistency, amount, and odor. These characteristics may indicate pulmonary infection. Adequacy Was the client able to

3) The client will be able to modify

behaviors conserve energy.

to

Reference: 1) Refer client to Medical-Surgical rehabilitation programs Nursing: A Nursing for general body Process Approach, exercises. Ignatavicius, et. al, 580 Exercises improve overall muscle function and allow more efficient use of oxygen by the muscles. 2) Formulate a plan with the client for pacing activities of daily living. a) Encourage sitting for most activities, such as peeling potatoes or talking on the telephone. b) Teach the client to always breathe during an activity and never to hold his breath. c) Be aware that activities involving the arms consume the most energy. d) Plan rest periods during more strenuous activities. 3) Evaluate nutritional state of the client and

maintain patent airway and normal breathing patterns? _Yes _No Why? Efficiency Were the resources available to the nurse nd the client maximized? _Yes _No Why?

Reference: Medical-Surgical Nursing, Luckmann, et. Appropriateness al, pp. 1998 Were interventions appropriate to client Pacing conserves energy situation? that is needed for _Yes _No breathing. Why?

Reference: Acceptability Reference: Were the Medical-Surgical interventions Nursing, Luckmann, et. acceptable to the al, pp. 1997 client and significant others? _Yes _No Why? Adequacy Were interventions the

offer support. a) Compare baseline weight to present weight. b) Evaluate laboratory data: serum total protein and albumin levels. c) Assist the client in choosing foods that are easy to chew and swallow and that are high in calories. d) Assist the client by cutting food and feeding if the client tires easily. e) Suggest that the client eats small, frequent meals.

adequate to address the clients needs and problem? Eating consumes energy _Yes _No needed for breathing; Why? clients whi have increased work of breathing have higher calorie requirements. Reference: Reference: Medical-Surgical Nursing, Luckmann, et. al, pp. 1997