West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Nursing Nursing
Clustered Cues Rationale Outcome Criteria Rationale Evaluation
Diagnosis Interventions
Impaired gas Impaired gas The client will be Assess for altered Patients will
exchange related exchange is excess or able to maintain breathing pattern: adapt their
to the deficit in oxygenation optimal gas breathing
destruction of and/or carbon dioxide exchange by a. increased patterns over
alveolar walls elimination at the proper work of time to facilitate
alveoli-capillary positioning, breathing gas exchange.
membrane. breathing b. Abnormal
exercises, rate, rhythm,
Emphysema is a
hydration, oxygen and depth of
chronic obstructive
administration respiration
pulmonary disease
and c. abnormal
(COPD) that is
bronchodilators chest
characterized by
as evidenced by excursions
abnormal,
permanent
Posture, upright
enlargement of the air
Assess generalized positioning and
spaces past the
appearance. mental alertness
terminal bronchioles,
cue the nurse to
which results in the
the severity of the
destruction of
COPD
respiratory walls.
exacerbation.
In emphysema, the
Assess for Restlessness is an
affected terminal
restlessness, early sign of
bronchioles contain
headache, hypoxia. Lethargy
mucous plugs that,
confusion, dizziness, and somnolence
when they are
reduced ability to are late signs.
enlarged, eventually
follow instructions.
result in the loss of Hypoxia or
elasticity of the lung hypercarbia may
parenchyma, thus Monitor vital signs. cause initial
causing difficulty hypertension with
in the expiratory restlessness and
phase of respiration. progress to
The alveolar walls are hypotension and
destroyed by somnolence.
abnormal levels
of enzymes Dyspnea often
(proteases) that break increases anxiety,
down respiratory Assess level of and anxiety
walls. Gas exchange is anxiety and fear. increases oxygen
impaired by the use by tissues.
reduced surface area Anxiety may be
that results from the an indication of
destruction of alveolar worsening
walls. hypoxemia.

Promote more
Emphysema is a effective breathing
disorder in which the pattern for better
alveolar walls are gas exchange:
destroyed. This a. Upright and
destruction leads to a. Instruct in semi-
permanent positioning for fowler’s
overdistention of air optimal positions
spaces. Air passages breathing. favor better
are obstructed as a lung
result of these expansion;
changes. Research has the
shown that the diaphragm
enzymes protease and is pushed
elastase can attack downward.
and destroy the If the
connective tissue of patient is
the lung. Emphysema bedridden,
may result from a turning
breakdown in the from side to
lungs normal defense side at least
mechanism against 2 hours
these enzymes. promotes
b. Teach and better
Difficult expiration in demonstrate aeration of
emphysema is the pursed-lip all lung
result of the breathing. lobes.
destruction of the
walls between the b. This
alveoli and septa c. Teach NA to encourages
collapse, and loss of use abdominal more
elastic recoil. As the breathing. complete
alveoli and septa exhalation.
collapse, pockets of d. Teach the
air form between the therapeutic c. This assists
alveolar spaces and use of splint in a more
within the lung when forceful
parenchyma. This coughing exhalation.
process leads to
increased ventilatory d. To protect
dead space from areas Collaborative: site injury
that do not participate and
in gas or blood Monitor ABGs and minimize
exchange. oxygen saturation. pain from
coughing

The normal structure

and function of the
human lung is
dependent on the Increasing paCO2
maintenance of the and decreasing
connective tissue PaO2 are signs of
matrix. These respiratory
structural failure. As the
macromolecules patient’s
provide the template condition begins
for normal to fail, the
parenchymal cell respiratory rate
architecture on which will decrease and
efficient gas exchange PaCO2 will begin
depends. to rise. The COPD
patient has a
significant
Bronchospasm decrease in
reduces the caliber of pulmonary
the small bronchi. reserves, and any
Increased mucus Administer oxygen physiological
production along with as indicated. stress may result
deceased mucociliary in acute
action, contributes to respiratory
further reduction in failure.
the caliber of the Noninvasive
bronchi and results in measurement of
decreased airflow and oxygen saturation
decreased gas by pulse oximetry
exchange. This is provides early
further aggravated by recognition of
the loss of lung impaired
elasticity that occurs oxygenation
with COPD. status.
Administer
Sources:
bronchodilators, COPD patients
Diseases and
antibiotics, and who chronically
Disorders: A Nursing
anti-muscarinic and retain carbon
Therapeutic Manual
anti-inflammatory dioxide depend
2007 3rd Edition by
drugs as indicated. on “hypoxic
Sommers et al
drive” as their
Perform chest stimulus to
Nurse’s Pocket Guide
physiotherapy and breathe. When
2008 11th Edition by
postural drainage applying oxygen,
Doengesa et al
after administration close monitoring
of bronchodilator as is imperative to
Medical-Surgical indicated. prevent unsafe
Nursing 2004 7th increases in the
Edition by Black & Plan activity with patient’s PaCO2
Hawks interspersed rest which could result
periods and after in apnea.
Brunner and bronchodilator
Suddarth’s Textbook treatments. These reduce
of Medical-Surgical airway resistance,
Nursing 2004 10th treat infection,
Edition by Smeltzer & and facilitate
Bare secretion
removal.
Research Article: Role
of Connective Tissue
proteases in the T o assist in the
pathogenesis of Sources: removal of
chronic inflammatory Nurse’s Pocket secretions.
lung disease by JE Guide 2008 11th
Gadek at el Edition by Doenges
et al
Medical-Surgical
Nursing 2004 7th
Edition by Black & Pacing activities
Hawks will help patient
conserve energy.
Brunner and
Suddarth’s
Textbook of
Medical-Surgical
Nursing 2004 10th
Edition by Smeltzer
& Bare

Nursing Care Plans

2007 6th Edition
Gulanalick/Myers