NURSING CARE PLAN Problem Identified: Impaired Gas exchange Nursing Diagnoses: Impaired Gas Exchange r/t altered

oxygen supplyobstruction of airways by secretions, bronchospasm, air-trapping, alveoli destruction Cause Analysis: Chronic airflow limitations (caused by a mixture of small airway disease) and airway inflammation may affect the diffusion of gases in the alveoli, thus resulting to impairment of gas exchange. (Doenges, M.E. Nursing Care Plan, p 120)
Cues Subjective: Kinahanglan nako ang oxygen para makaginhawa ko ug tarong as verbalized by the patient. STO: Within 8 hours of nursing interventions, the patient will participate in treatment regimen within level of ability and situation and Objectives Independent: Assessed respiratory rate and depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak or converse. Elevated head of bed and assist client to assume Objective: Vital Signs taken: RR- 26 bpm BP- 140/70mmHg PR- 89 Presence of fine crackles all over upon auscultation Productive cough with white sputum. with O2 inhalation @2 L/min via nasal cannula Chest PA View: (+) Minimal pleural thickening, left lower chest. O2 saturation: 92% Evaluated sleep patterns, noted reports of difficulties and whether client feels well rested. Provided quiet environment and group care and monitoring activities to allow periods of uninterrupted sleep. Limited stimulants such as caffeine. Encouraged position of comfort. LTO: Within 3 days of nursing interventions the patient will be able to demonstrate improved ventilation and adequate oxygenation as evidenced by oxygen saturation within normal range (95-100%). Auscultated breath sounds, noting areas of decreased airflow and adventitious sounds. Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered, moist crackles may indicate interstitial fluid or cardiac decompensation. Multiple external stimuli and presence of dyspnea and hypoxemia may prevent relaxation and inhibit sleep. position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep, slow or pursed lip breathing as individually needed and tolerated. Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase PaO2. LTO: After 3 days of nursing interventions, the patients oxygen saturation increased to 95-96%. Useful in evaluating the degree of respiratory distress and chronicity of the disease process. Nursing Interventions Rationale STO: After 8 hours of nursing interventions, the patient cooperatively participated in treatment regimen. Evaluation

 Monitored vital signs and cardiac rhythm.

Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function.

Collaborative: Administer supplemental oxygen judiciously via nasal cannula at 2L/min. Used to correct and prevent worsening of hypoxemia, improve survival, and quality of life. Supplemental oxygen can be provided during exacerbations only, or as a long-term therapy. Administered medications as indicated: Pulmodual 5-6 drops Q6H RTC Inhaled anticholinergic agents are now considered the first-line drugs for clients with stable COPD because studies indicate they have a longer duration of action with less toxicity potential, whereas still providing the effective relief of the beta-agonists.

Reference: Doenges, M.E. (2008). Nursing Care Plan, 8th ed. p. 126-127