Patient: D.

Age: 82 years old

Gender: Male Attending Physician: Dr. Garlitos Expected Outcome After 8 hours of nursepatient intervention, the patient will be able to: 1. Demonstrate improved ventilation and adequate O2, and absence of symptoms of respiratory distress. Nursing Intervention Independent nursing interventions: Justification Independent nursing interventions: Evaluation After 8 hours of nurse-patient intervention, the patient was be able to:

Medical Diagnosis: COPD in AE, Varicelle infection Assessment Data Actual/Abnormal Cues: Patient verbalized, kis.a budlayan ko mag-ginhawa na daw indi gid maayo ang akon baga. Productive cough Respiratory rate of 26 cpm tachypnic; with irregular rhythm of the rise and fall of chest. Nursing Diagnosis Impaired gas exchange r/t ventilation perfusion imbalance as evidenced by dyspnea, productive cough, abnormal respiratory rate and rhythm, and abnormal arterial blood gas values. Rationale Predisposing factors: - Old age (82 years old) - Gender: Male Precipitating factors: - History of cigarette smoking - Environmental exposure to outdoor air pollution - Upper respiratory tract infection entrance of pathologic agents in conjunction with harmful pollutants Irritation of the airways causing inflammation Bodys compensatory mechanism release histamine, histamine and prostaglanidin Increase capillary permeability

1.1 Assess respirations: quality, rate, pattern, depth and breathing effort.

Definition: Excess or deficit in Arterial Blood Gas oxygenation and/or results: decrease pH= CO2 elimination at 7.235 (abnormal) and the alveoli-capillary increase PCO2= 47.2 membrane meq/dL (abnormal) Risk Factors: Poor ventilation and hot weather condition in the ward. Strengths: Strong spiritual Source: Nursing Care Plan 6th Ed by Doenges, et al pp 800-801

1.1 Rapid, shallow breathing and hypoventilation affect gas exchange by affecting CO2 levels. Flaring of the nostrils, dyspnea, use of accessory muscles, tachypnea and /or apnea are all signs of severe distress that require immediate intervention.

1.2 Monitor vital signs.

1.2 Initially with hypoxia and hypercapnia blood pressure (BP), heart rate and respiratory rate all increase. As the condition becomes more severe BP may drop, heart rate continues to be rapid with arrhythmias and respiratory failure may

belief Good family support Disciplined Good compliance to treatment regimen Willingness to change Cooperation

Fluid and cellular exudation Decrease O2 and CO2 passage Impaired gas exchange r/t ventilation perfusion imbalance Source: Crib, N. (2008, 26 November). Pathophysiology of COPD. Retrieved August 30, 2012, from http://nursingcrib.com/ pathophysiology/ pathophysiology-ofchronic-bronchitis-copd/

ensue. 1.3 Auscultated breath sounds noting crakles, wheezes 1.3 Reveals presence of pulmonary congestion/ collection of secretion, indicating need for further intervention. 1.4 For mobilization of secretions.

1.4 Maintain adequate intake and output but avoid fluid overload

2. Verbalize understanding of causative factors and appropriate intervention.

1.5 Elevated head of bed/ position client appropriately, provide airway adjuncts and suction as indicated. 2.1 Discuss implications of smoking related to illness/ condition

1.5 To maintain airway

2.1 Smoking is the leading cause of COPD which accounts for high mortality rate.

2.2 Discuss reasons for allergy testing when indicated. Review individual drug regimen and ways of dealing with side effects. 2.3 Reinforce need for

2.2 To rule out allergy to the prescribed drug and prevent complications. Enforce knowledge for patients benefit.

adequate rest while encouraging activities and exercise.

2.3 To decrease dyspnea and improve quality of life.

3. Participate in the treatment regimen within the level of ability/situation.

2.4 Emphasize importance of nutrition most especially high protein foods such as fish, milk, green leafy vegetables and fruits.

2.4 To repair damage tissues and improve stamina.

3.1 Encouraged frequent deep breathing/ coughing exercises.

3.1 Promotes optimal chest expansion and drainage of secretions.

3.2 Pace activities and provide rest periods to prevent fatigue.

3.2 Even simple activities, such as bathing, can increase oxygen consumption and cause fatigue.

Collaborative interventions: 1.1 Administer prescribed meds by the physician such as Budesonide and Combivent via

Collaborative interventions: 1.1 To loosen secretions of the airways thus improving gas exchange.

inhalation.