NURSING DIAGNOSIS Impaired gas Subjective: exchange related Nahihirapan ako to ventilationhuminga.

AVB the perfusion mother of the patient inequality secondary to COPD Objective: VS: T: 36.9C RR: 28 cpm PR: 120 bpm BP: 140/90 (+) Dyspnea Weak in appearance Pallor

ASSESSMENT

SCIENTIFIC EXPLANATION Inhalation of pathogens Activation of circulating macrophages Injury due to Inflammatory response Narrowing of the small peripheral airways Injury-repair prcess scar tissue fomation Impaired gas exchange Narrowing of the airway lumen

PLANNING

After 7 hours of effective nursing intervention, the patient will be able to: Assess the contributing factors that aggravates verbalize patients breathing normal pattern. respiration or normal Place the patient in breathing Semi-Fowlers pattern as position. evidenced by: Encourage the pt to do deep breathing and Vital signs coughing exercises. within the normal range particularly the Encourage patient to respiratory rate maintain calm attitude. from 15-20 cpm. Participate in treatment Observe proper visit regimen such hours and give the as: patient enough time to rest - Breathing exercises Provide well ventilated room
(-) dyspnea

NURSING INTERVENTION Assess the rate and depth of respiration.

RATIONALE For baseline data

EVALUATION After 7 hours of effective nursing intervention, goal was met AEB: The patient verbalized normal respiration or normal breathing pattern as evidenced by:
(-) dyspnea

To eradicate or minimize these contributing factors To facilitate maximum expansion of the lungs

To promote expectoration of secretions and relaxation To promote wellness and decreases metabolic demand. To avoid disturbance and the pt could rest

Vital signs within the normal range RR= 20cpm Participated in treatment regimen such as: Breathing exercises

Airway obstruction

ventilationperfusion inequality

To promote

ventilation Impaired gas exchange Health teaching on proper hygiene particularly in oral. COLLABORATIVE: Administer nebulization as ordered.

To promote hygiene and fresh breath.

To promote bronchodilation

ASSESSMENT Subjective: Mabilis akong mapagod, as verbalized by the patient Objective: Weak Pallor (+) dyspnea cold clammy skin changes in HR and BP w/ activity VS: T: 36.9 C P: 95 bpm R: 25 cpm BP: 140/90 mmHg

NURSING DIAGNOSIS Activity intolerance r/t imbalance between myocardial oxygen supply and demand

SCIENTIFIC EXPLANATION Imbalance of blood supply and demand

Myocardial Ischemia

Decrease of Myocardial oxygen supply

Increase of cellular hypoxia

Altered cell membrane int.

NURSING INTERVENTION After 7 hours of Record HR and BP effective nursing changes before, intervention, the during and after patient will be able activity to: Position the patient Participate in a semi-fowlers willingly in position necessary/desi Encourage bed rest red activities Use identified techniques to Instruct patient to enhance avoid increase activity abdominal pressure intolerance like straining during defecation Encourage to limit strenuous activities Explain pattern of graded increase of activity level like progressive ambulation and resting after meals Ascertain ability to stand and move about and degree of assistance necessary/use of

PLANNING

RATIONALE To determine pts response to activity To allow for rest and increase available oxygen Reduces myocardial workload and oxygen consumption Activities that require holding breath and bearing down can result in bradycardia and rebound tachycardia w/ elevated BP Because strenuous activities increase cardiac work Progressive activity provides a controlled demand on the heart, increase strength and preventing overexertion To determine current status and needs associated with participation in needed/desired

EVALUATION After 7 hours of effective nursing intervention, goal was met AEB: Patient participated willingly in necessary/desi red activities Used identified techniques to enhance activity intolerance

Decrease of myocardial contractility

Decrease of cardiac output

Decrease of arterial pressure

Stimulation of Baroreceptors

equipment Promote comfort measures and provide for relief of pain

activities To enhance ability to participate in activities

Stimulation of sympathetic receptors

Increase Increase myocardial Peripheral constriction contractility

Increase HR Increase after load

Decrease diastolic filling Decrease myocardial tissue perfusion

Increase myocardial oxygen demand

ASSESSMENT Subjective: Mabilis akong mapagod AVB the patient Objective: Bipedal edema (+) dyspnea Weak in appearance

NURSING DIAGNOSIS Decreased cardiac output r/t altered stroke volume

SCIENTIFIC EXPLANATION Increased blood pressure

PLANNING After 7 hours of effective nursing interventions, the patient will be able to: Verbalize knowledge of the disease process, individual risk factors and treatment regimen. Report decreased episodes of dyspnea Participate in activities that reduce the workload of the heart such as: - Stress management - Rest plan - Cessation of smoking - Treatment regimen

NURSING INTERVENTION Monitor and record BP and pulse. Institute bedrest with client in lateral position. instruct patient to avoid food high in cholesterol and sodium discuss significant signs and symptoms that needs to be reported immediately to a health care provider such as muscle cramps headache, dizziness teach home monitoring of weight, pulse and blood pressure

RATIONALE For baseline data

EVALUATION After 7 hours of effective nursing interventions, goal was met AEB: Patient verbalized knowledge of the disease process, individual risk factors and treatment regimen. Reported decreased episodes of dyspnea Participated in activities that reduce the workload of the heart such as: - Stress management - Rest plan - Cessation of smoking - Treatment regimen

Vasospasm

Increased vascular resistance Difficulty of the heart to pump blood

Increases venous return, cardiac output, and renal perfusion. this types of food can worsen the patients disease condition This can prevent worsening the patients condition because this may be signs of mineral losses to detect changes and allow immediate and timely

VS: T: 36.9C RR: 28 cpm PR: 120 bpm BP: 140/90 Increased cardiac workload

Decreased cardiac output

interventions Administer Furosemide as ordered If BP does not respond to conservative measures, short-term medication may be necessary in conjunction with other therapies