Nursing diagnosis 1 : Impaired gas exchange related to
decreased ventilation and mucus plug.
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Interventions
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Rationale
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1.
Assess and
document respiratory rate and pattern, pulse oximetry every shift, and ABGs
as ordered. Report changes.
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1.
Early
recognition of deteriorating respiratory function can improve patient
outcomes.
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2.
Maintain
low-flow oxygen therapy as ordered (not more than 3L/min)
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2.
Oxygen therapy
helps to correct hypoxemia.
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3.
Assist the
patient to high Fowler’s position as needed.
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3.
Promotes fuller
lung expansion.
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4.
Administer
bronchodilators as prescribed. Assess for adverse effects of tachycardia and
arrhythmias.
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4.
Bronchodilators
relax bronchial smooth muscle which improving air flow.
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5.
Teach the
patient to breath using the diaphragm.
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5.
Diaphragmatic
breathing deters the shallow, rapid and inefficient breathing.
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Nursing diagnosis 2 : Ineffective airway clearance related
to excessive secretion and ineffective coughing.
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Interventions
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Rationale
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1.
Teach the
patient effective coughing techniques.
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1.
Loosen mucus
and ease expectoration, helping to conserve patient energy.
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2.
Promote the
patient to drink water at least 8 glasses of fluid per day, unless
contraindicated
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2.
Adequate
hydration helps to thin secretion.
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3.
Perform chest
physiotherapy, if ordered.
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3.
Helping in
loosen secretions.
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4.
Monitor the
patient’s performance of incentive spirometry as ordered.
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4.
Incentive
spirometry helps promote lung expansion.
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5.
Suction the
patient to remove mucus from the back of the throat and mouth.
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5.
Thick
secretions are difficult to expectorate and patient may not have the energy
to do so.
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Nursing diagnosis 3 : Activity intolerance related to inadequate
oxygenation and dyspnea.
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Interventions
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Rationale
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1.
Gradually
increase the client’s daily activities as tolerance increases.
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1.
Sustained
moderate breathlessness from supervised exercise improve accessory muscle
strength and respiratory function.
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2.
Teach the
client effective breathing techniques such as diaphragmatic and pursed-lip
breathing.
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2.
Diaphragmatic
breathing-deters the shallow, rapid, inefficient breathing.
3.
Pursed-lip
breathing-breathing slows expiration, keeps alveoli inflated longer, and
provides some control over dyspnea.
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3.
Maintain
supplemental oxygen therapy, as needed.
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4.
Supplemental
oxygen increases circulating oxygen levels and improves activity intolerance.
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4.
Provide
emotional support and encouragement.
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5.
Fear of
breathlessness may disrupt increased activity.
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5.
Plan adequate
rest periods according to client’s daily schedule.
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6.
Allow the body
a period of flow energy expenditure.
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Nursing diagnosis 4 : Anxiety related to acute breathing
difficulties and fear of suffocation.
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Interventions
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Rationale
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1.
Provide a quiet
and calm environment
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1.
Reducing
external stimuli promotes relaxation.
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2.
Do not leave
the client alone during periods of acute breathlessness.
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2.
The client
needs reassurance that help is available if needed.
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3.
Acknowledge the
client’s fear and give positive reinforcement for efforts.
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3.
Fear triggers
dyspnea and dyspnea increases fear. Clients report a nurse’s acknowledgement
of their fear assuaged their fear and alleviated their breathing difficulty.
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4.
Demonstrate
breathing techniques and have the client imitate the technique with the
nurse.
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4.
Role modeling
breathing techniques for the client to imitate will reduce the need to spend
energy in concentration.
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5.
Encourage the
client to use breathing techniques especially during times of increased
anxiety. Coach the client through the breathing exercises.
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5.
Concentrating
on diaphragmatic or pursed-lip breathing slows the respiratory rate and gives
the client a sense of control.
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Nursing diagnosis 5 : Altered nutrition : less than body
requirement related to reduced appetite, decreased energy level and dyspnea.
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Interventions
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Rationale
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1.
Encourage a
rest period of 1 hour before and after meals. Provide frequent small
feedings.
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1.
Helps reduce
fatigue during mealtime, and provides opportunity to increase total caloric
intake.
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2.
Avoid
gas-producing foods and carbonated beverages.
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2.
Can produce
abdominal distension, which hampers abdominal breathing and diaphragmatic
movement and can increase dyspnea.
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3.
Avoid very hot
or very cold foods.
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3.
Extremes in
temperature can precipitate/aggravate coughing spasms.
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4.
Weigh as
indicated.
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4.
Useful in
determining caloric needs, setting weight goal, and evaluating adequacy of
nutritional plan.
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5.
Administer
supplemental oxygen during meals as indicated.
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5.
Decreases
dyspnea and increases energy for eating, enhancing intake.
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