Anda di halaman 1dari 3

SUBJECTIVE OBJECTIVE CUES CUES Maglisod Restlessness ko ug ginhawa, Dyspnea as verbalized Use of accessory by the muscles patient.

nt. Irregular respiration RR = 18 cpm Presence of crackles noted Chest PA: Pulmonary Emphysema

NURSING DIAGNOSIS Impaired gas exchange related to alveoli obstruction as evidenced by dyspnea, reduced activity tolerance secondary to pulmonary emphysema.

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolicapillary membrane[this may be an entity of its own but also ay be an end result of other pathology

SCIENTIFIC PLANNING ANALYSIS Shortness of After 4 hours breath is the of nursing care most common interventions, symptom of the patient emphysema. Coug will be able h, sometimes to: caused by the Demonstrate production of improved mucus, and ventilation wheezing may and adequate also be oxygenation symptoms of of tissues emphysema. You may notice that your tolerance Participate in treatment for exercise de regimen like creases over breathing time. Emphysema exercise, usually effective develops coughing, and slowly. You may use of not have any oxygen. acute episodes of shortness of breath. Slow Verbalize deterioration understanding is the rule, of causative and it may go factors and unnoticed. This appropriate

INTERVENTIONS Independent: Monitor vital signs, note for changes in cardiac rhythm. Elevated head of bed, position client appropriately. Encouraged frequent deep breathing and coughing exercises. Auscultated breath sounds noting crackles.

RATIONALE

EVALUATION After 4 hours of nursing care interventions, the patient will be able to:

Hypoxia is associated with signs of increased breathing effort. Demonstrated To maintain improved airway. ventilation and adequate oxygenation of tissues

Promotes optimal chest Participated in treatment expansion and regimen like drainage of breathing secretions. exercise, effective Reveals coughing, and presence of use of pulmonary oxygen. congestion or collection of Verbalized secretion, understanding indicating of causative need for factors and further

with an interrelatedness between airway clearance and/or breathing pattern problems]

is especially the case if you are a smoker or have other medical problems that limit your ability to exercise.

intervention.

intervention.

appropriate intervention.

Source: Doenges, E., Moorhouse,M.F. Murr,A., Nurses Pocket Guide, 11th edition,pg.322327

Source: http://www.emed icinehealth.com /emphysema/page 3_em.htm#Emphys ema Symptoms