NCP

Assessment
Subjective
“I have difficulty of breathing”, as verbalized by the patient.
“I have headache upon awakening”, as verbalized by the patient.
Objective
Temp. 37.2 degrees Celsius
PR: 146 BPM
RR: 19 breaths/min
BP: 140/90 mmHg
Confusion; restlessness; pale skin; abnormal breathing; nasal flaring; abnormal ABGs/arterial pH as evidenced by hypoxia
Nursing diagnosis
Impaired gas exchange related to inflammatory process, collection of secretions affecting oxygen exchange across alveolar membrane, and hypoventilation possibly evidence by restlessness/change in mentation, dyspnea , tachycardia, pallor and abnormal ABGs/arterial pH evidence of hypoxia
Plan
Client will:
Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal limits and absence of respiratory distress
Participate in treatment regimen(e.g. breathing exercises, effective coughing, use of oxygen)within level of ability/situation
Interventions

*Maintain oxygen administration device as ordered to maintain oxygen saturation at 90% or greater

* For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus.

* Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees).

* Routinely check the patient’s position so that he or she does not slide down in bed

* Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowler’s position whenever possible.

* Pace activities and schedule rest periods to prevent fatigue


* Change patient’s position every 2 hours.

* Encourage deep breathing, using incentive spirometer as indicated

* Encourage or assist with ambulation as indicated


*assist with splinting the chest

*Observe signs of respiratory distress(increased rate/restlessness and pallor)

*Teach the patient appropriate deep breathing and coughing
Rationale

* This provides for adequate oxygenation.



* These promote activity and facilitate more effective ventilation


*This promotes lung expansion and improves air exchange



* This would cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment.
* High-Fowler’s position allows for optimal diaphragm excursion. When patient is positioned on side, the good side should be down

* Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption.
* This facilitates secretion movement and drainage.

* This reduces alveolar collapse.


* This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing.
*Splinting optimizes deep breathing and coughing efforts.
*These clinical manifestation would be early indicators of hypoxia


*Facilitates adequate air exchange and secretion clearance
Evaluation

Outcome met. The patient demonstrated improved oxygen ventilation and adequate oxygenation. Added to that he participated in treatment regimen for breathing exercise, effective coughing, and use of oxygen