ASSESSMENT S - Dyspnea, Insipatory Chest pain, Cough and hemoptysis as complained by the patient.

O Dyspnea - Prolonged expiration phases - Decreased inspiratory pressure

DIAGNOSIS Ineffective Breathing Pattern r/t decreased lung expansion as evidenced by dyspnea and cough

PLANNING After 4 hours of nursing interventions the patient will be able to establish a normal/effective respiratory pattern as evidenced by absence of cyanosis and other signs/symptoms of hypoxia with ABGs within normal/acceptable range

INTERVENTION
Note emotional responses (e.g., gasping, crying, reports of tingling fingers) Have client breathe into a paper bag, if appropriate,

RATIONALE
Anxiety may be causing/exacerbating acute or chronic hyperventilation

EVALUATION After 4 hours of nursing interventions the patient was be able to establish a normal/effective respiratory pattern as evidenced by absence of cyanosis and other signs/symptoms of hypoxia with ABGs within clients normal/acceptable range

To correct hyperventilation (Research suggests this may not be effective and could actually stress the heart/respiratory system, potentially lowering O saturation, especially if the hyperventilation is not simply anxiety based) To assist client in taking control of the situation To limit level of anxiety

Encourage slower respirations, use of pursed-lip technique Maintain calm attitude while dealing with patient Avoid overeating/gas forming foods

May cause abdominal distention

ASSESSMENT S -Dyspnea and Visual Disturbances as complained by the patient O - Tachycardia - Hypoxia - Somnolence: Lethargy

DIAGNOSIS Impaired Gas Exchange r/t Ventilation perfusion imbalance (altered blood flow), alveolar-capillary membrane changes (atelectasis) as evidenced by profound dyspnea and somnolence

PLANNING After 4 hours of nursing interventions the patient will be able to Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress

INTERVENTION
Assess nutritional status including serum albumin level and body mass index

RATIONALE
Resulting in a loss muscle mass in the respiratory muscles which can lead to respiratory failure

EVALUATION

After 4 hours of nursing interventions the patient was be able to Evaluate pulse To assess for Demonstrate oximetry to respiratory improved determine insufficiency ventilation and oxygenation; evaluate adequate lung volumes and oxygenation of forced vital capacity tissues by ABGs Elevate head of Promotes optimal within clients bed/position client chest expansion an normal limits and appropriately, drainage of secretions absence of provide airway symptoms of adjuncts and suction, respiratory as indicated distress
Help the client eat small frequent meals and use dietary supplements as necessary Encourage adequate rest and limit activities to within client tolerance. Promote calm/restful environment Having a BMI less than 21 has been associated with earlier mortality in patients with COPD Helps limit oxygen needs/consumption

ASSESSMENT S Chest Pain and Dyspnea as complained by the patient

DIAGNOSIS

PLANNING After 4 hours of nursing interventions the patient will be able to Demonstrate increased perfusion as individually appropriate (balanced I/O, absence of edema, free pain/discomfort)

INTERVENTION
Investigate reports of chest pain, note precipitating factors, changes in characteristics of pain episodes Note presence of/degree of dyspnea, cyanosis, hemoptysis Monitor vital signs, hemodynamics, heart sounds, and cardiac rhythm Caution client to avoid activities that increase cardiac work-load (e.g., straining at stool)

RATIONALE
To note degree of impairement/organ involvement

EVALUATION After 4 hours of nursing interventions the patient was be able to Demonstrate increased perfusion as individually appropriate (balanced I/O, absence of edema, free pain/discomfort)

Ineffective Cardiopulmonary Tissue Perfusion r/t exchange problems at alveolar level as O - Hemoptysis evidenced by - Presence of laboratory evidence edema in right of lower extremity ventilation/perfusion mismatch and dyspnea

To note degree of impairement/organ involvement To maximize tissue perfusion

To maximize tissue perfusion

Assist with treatment of To improve tissue underlying conditions perfusion/organ (e.g., stent replacement, functuion surgical reperfusion procedures, medications, fluid replacement/rehydration, nutrients, treatment of sepsis, etc.)