Nursing Diagnosis: Impaired gas exchange R/T alveolar-capillary membrane changes AEB dyspnea upon exertion Long Term

Goal: Patient will gradually increase activity level without dyspnea prior to discharge

Intervention Monitor vital signs q 4 hrs

Assess breath sounds q 4 hrs

Encourage the correct use of ISP q 1hr

Rationale Watch for accessory muscles and nasal flaring. Normal respiration rate is 14-18 bpm in the adult. Oxygen saturation of less than 90% or partial pressure of less than 80mmHg indicates significant oxygenation problems. Nanda pg.402-403 The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbation of COPD, lung sounds maybe diminished or distant with air trapping. Nanda pg.402-403 This technique can help increase sputum clearance and decrease cough spasms. Nanda pg.129-130

Outcome Criteria Patient will exhibit stable vital signs during hospital stay.

Evaluation Unmet: Respiratory rate noted to be frequently above 20bpm.

Patient will exhibit clear breath sounds during hospital course.

Unmet: Bilateral lower lobe wheezes noted with diminished breath sounds.

Patient will demonstrate the correct use of ISP q 1hr.

Unmet: Patient was not able to take deep breaths. Very shallow breaths noted.

Assess for signs of cyanosis q shift

Note the color of the tongue and mucous membranes (especially central cyanosis of the tongue and oral mucosa) is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be due to the activation of the CNS or exposure to cold and may not be serious. Nanda pg. 403 Body movement helps mobilize secretions. Nanda pg. 130 Bronchodilator medications commonly used are beta 2 adrenergic agonists, anticholinergic agents and methylxanthines. The choice of bronchodilator depends on availability and the patients response. Lewis pg. 617 Especially electrolytes including k+, Mg, digoxin level and BNP. A comparative study of aldosterone antagonists used for LVSD found that monitoring k+ and kidney function are essential to minimize the potential for life threatening hyperkalemia that can occur from renal insufficiency, diabetes mellitus, advanced heart failure, and concurrent drug therapy. Nanda pg. 200

Patient will not exhibit signs of hypoxia during hospital course.

Met: No signs of hypoxia noted

Encourage activity as tolerated

Patient will gradually increase activity during hospital course. Patient will show improvement with shortness of breath.

Administer Duoneb 3ml unit dose via nebulizer QID

Unmet: Activity tolerance limited due to shortness of breath upon exertion. Unmet: Patient continues to have shortness of breath.

Assess labwork, electrolytes and ABGs daily when available

Patient will maintain normal bloodwork parameters during hospital course.

Met: Patient maintained normal bloodwork parameters.