Dianne Alexis Uytiepo BN4K Patients name: R.J. Gender: Male Age: 76 y.o.

Chief complaint: Difficulty of breathing Attending Physician: Dr. Garlitos

Assessment Abnormal cues: Client verbalized nabudlaya n ku mag ginhawa Difficulty of breathing Body weakness wheezes RR= 26 cpm O2=4lL/mi n Risk-related Factors: Low socioecono mic status Poor access to medical care Unsafe Nursing Diagnosis Impaired gas exchange related to acute exacerbation Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway Reference: Nurses Pocket Guide edition 11 Rationale

Diagnosis: CAP MR; COPD not in AE

Desired Outcomes After 4 days of rendering care the patient will be able to: 1. Demonstrate improved ventilation and adequate oxygenation of tissues 2. Attain normal breathing pattern: 1220 cpm 3. Participate in treatment regimen

Nursing Interventions

Justification To maintain airway

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

Predisposing factors: >age: 76 y.o. >gender: male Precipitating factors: >low socioeconomic status >poor access to medical care >unsafe environment

Independent Elevate head of bed/ postion client appropriately, provide airway adjunts and suction, as indicated Encourage frequent position changes, deep breathing exercises, and coughing exercises Auscultate breath sounds, noting areas of decreased airflow or presence of adventitious sound Reinforce need for adequate rest, while encouraging activity and exercise

Promotes optimal chest expansion and drainage of secretions Presence of wheezes may indicate bronchospasm/ retained secretions To decrease dyspnea and quality of life

Entry of noxious particles or gases to the lungs Release of mediators Abnormal inflammation of lungs Chronic inflammation Scar tissue formation

Collaborative: Administer Aids in

environme nt Strengths: family support from daughter

Narrowing of airway lumen Airflow limitation Difficulty of breathing, body weakness and wheezes Impaired gas exchange

medications as prescribed: mucolytics or expectorants Provide supplemental fluid

reduction of bronchospasm and mobilization of secretions Fluids are required to replace losses and aid in mobilization of secretions