DAPHNIE MAE ESTACIO

COPD: EMPHYSEMA

Environmental: Long Term

Genetic Predesposition: A-1
exposure to cigarette smoke or
Antitrypsin deficiency
pollution

Increased
inactivation of lung
neutrophils elastase an Free Radicals
proteases
matrix proteases

Degrades Elastin by
Lung Inflammation:
Proteolysis
Incresed oxidative stress,
inflammatoruy cytokines
an protease function

Destruction od
alevolar walls and
capillaries Proteolytic destruction
of Lung parenchyma
ABG: pH 7.34 Risk for Activity Intolerance r/t
PaCO2: 47.92 imbalance between oxygen supply and
HCO3: 27.19 meq demand
Decreased Lung Respiratory
ability to prevent damage Acidocis
to lung tissue Diagnostic:
Monitor and record clients ability to tolerate activity, note
changes in the Vital Signs
Assess the client daily for appropriateness of activity
and bed orders.

Therapeutic:
Total Expiration Lungs don't fully More CO2 remains Provide emotional support and encouragement to the
Decreased Elastic client
takes longer time than emply and air is trapped and diffuses into the Hypoxemia
recoil to push air Refer the client to physical therapy to help increase
normal in the alveoli blood
ABG: pH 7.34 activity levels.
PaCO2: 47.92
HCO3: 27.19 meq Educative:
Teach the patient to avoid activities that causes fatigue
Prolonged
Expiration Enlarged air spaces Lung hyperinflation
impaired gas exchange related to
Ventilation-perfusion imbalance

Increased lung
Decreased Lung volume means
Diagnostics:
Compliance diaphragm is tonically Monitor Respiratory rate. depyth, eases of respiration,
contracted
watch out for use of accessory muscles
Note Pattern of respiration
Assess Breath sound, noting adventitious breath sounds.
Diaphragm can't
Risk for Activity Intolerance r/t Monitor oxygen saturation frequently.
Low Ventilation and flatten much further to
fatigue or weakness Oserve for cyanosis
Low perfusion generate deep breaths
Therapeutic:
Administer Oxygen therapy as odered
Diagnostic: Fatigue Position the patient in an upright or semi fowlers position
Determince ability of the client to perform ADL Increased Work of Help patient to take deep breathing .
or generalized
Monitor oxygen saturation, respiratory rate, pulse rate. Breathing to ventilate
weakness Rapid and Shallow
larger lung Eductive:
Breathing
Therapeutic: Teach the patient pursed lip breathing
Yes
Ensure that the client will perform activities that will not
compromise their condition. Collaborative:
RR: 30 CPM
Promote adequate rest . DYSPNEA Refer COPD client to a pulmonary rehabilitation program
Decreased Fluid Intake
Educative:
Shortness of Breath
Teach the client techniques such as controlled
on exertion , O2 Sat:
breathing techniques Ineffective Breathing
87%
Patten realated to
respiratory muscle fatigue
Dehydration

Diagnostics:
HCT: 70% Monitor Respiratory rate. depyth, eases of respiration
Note Pattern of respiration
Assess Breath sound, noting adventitious breath
sounds.
Monitor oxygen saturation frequently.
Deficient Fluid Volume r/t
inadequate fluid intake Therapeutic:
Administer Oxygen therapy as odered
Position the patient in an upright or semi fowlers position
Encourage patient to take deep breaths as prescribed
Diagnostic:
intervals.
Monitor total fluid intake and output every 4 hours
Observe fot dry tongue and mucous membranes
Eductive:
Monitor pulse, respiratory, and blood pressure.
Teach the patient pursed lip breathinh
Check skin turgor of the client
Help client identify an emergency plan .
Therapeutic:
Provide fluid replacement as per doctors order
Encourage patient to take sips of water frequently
Offer foods that
taht contains high amount of fluid in them.

Educative:
Teach the patient the importance of hydration.