About
Overdistention of alveoli with resultant destruction in the alveoli, thus decreased surface for gas exchange. One disease of many under the umbrella of Chronic Obstructive Pulmonary Disease or Chronic Airflow Limitation.
Assess
Lung sounds, use of accessory muscles, are they a CO2 retainer?, supplemental oxygen use, pulse oximetry, finger clubbing, previous medical and medication history, use of pursed-lip or diaphragmatic breathing, dyspnea with rest and/or with exertion, nutrition status, posture, finger clubbing, barrel chest.
Complications
Cor Pulmonale- monitor for hypoxia, dependant edema, pulmonary hypertension.
Lung transplantation or lung reduction surgery
Respiratory infections
Diagnosis
- Impaired airway clearance related to excessive, thick secretions
- Impaired gas exchange related to decreased exhalation
- Anxiety related to inability to breathe effectively
Goals
- The client will demonstrate proper pursed-lip breathing and abdominal breathing.
- The client will be able to state three energy conservation strategies.
- The client will remain free from infections.
Interventions
- Monitor clients lung sounds, VS, pulse oximetry, and anxiety levels at least every shift.
- Administer O2, as prescribed, being careful to not increase in clients who are CO2 retainers.
- Encourage adequate fluid intake, especially with mucolytics and expectorants, to assist in breaking down thick secretions.
- Encourage client to eat six small meals a day to maintain nutrition.
- Administer medications as prescribed, including mucolytics, bronchodilators, and antiinflammatories.
- Administer anxiolytics as ordered.
- Teach client energy conservation techniques, and positioning that may assist with decreasing episodes of dyspnea.
- Teach client how to administer own inhalers, obtaining a spacer if necessary.
- Teach the client respiratory breathing techniques, including pursed-lip breathing and diaphragmatic breathing.
- Teach client about medication regimen and disease management.
- Monitor for signs/ symptoms of complications.
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