Assessment Actual Abnormal Cues: Dyspnea Visual disturbances Headache upon awakening Confusion Restlessness Irritability Lethargy Abnormal

Abnormal ABG result Risk factors: Age Stress Smoking Occupation Exposure to airborne irritants

Nursing Diagnosis Impaired gas exchange related to inflammation of that lungs that altered the blood flow as evidenced by verbal reports of difficulty of breathing

Rationale Exposure to irritants

Desired Outcomes After 4 days of nursing intervention the client will be able to: 1.Demonstrate improved ventilation and adequate oxygenation of tissues within clients normal limits. 2. Participate in treatment regimen(e.g, breathing exercises, effective coughing, use of oxygen) within level of ability/situation. 3. Verbalize understanding of causative factors and appropriate intervention.

Intervention Independent: 1. Assess for respiratory depth, rate. Note use of accesory muscles, pursed lip breathing, inability to speak/converse 2. Routinely monitor skin and mucous membrane.

Justification

Evaluation After 4 days of nursing intervention, client was able to:

Toxic injury to endothelial and epithelial cells

1.To evaluate the degree of respiratory distress and chronicity of the disease process. 2.Cyanosis may be peripheral or central. Duskiness and central cyanosis indicates advance hypoxemia 3.Decrease of vibratory tremors suggest fluid collection or air trapping 1.PaCO2 usually is elevated and PaO2 is decreased: hypoxia is present in lesser or greater degree 2.to correct or prevent worsening of hypoxia 3.reduce dyspnea by controlling the anxiety

Accumulation of leukocytes Definition: -Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane.

3. palpate for crepitus

Inflammation of the lungs

Constriction of bronchus

Collaborative 1. Monitor serial ABG and pulse oximetry.

Impaired gas exchange

2. Administer oxygen therapy 3. Administer anti anxiety drugs