CONCEPT

PRESENTATION
ON
OXYGEN
INSUFFICIENCY
PERSONAL DATA 1
Name: Mr. Manohar G
Age: 65 year
Sex: Male
Marital status: Married , 3 children
Religion: Hindu
Occupation: Farmer
Educational level: primary level
Language spoken: kannada , tamil, telagu, hindi
Medical diagnosis: Exacerbation of COPD
Date of admission: 12/10/016
Date of discharge: 22/10/016
HEALTH PERCEPTION
Present health history: breathing difficulty, tachypnea, tachycardia,
swelling on the dorsum of the right foot.
Past health history: k/c/o COPD.
Allergies: none
Smoking: 7 per day
Chew tobacco: no
Use of alcohol : no
Family health history
Socio economic data
Health pattern
Rest and sleep
Elimination
INVESTIGATION DONE
Hb: 8.80 g/ dl( anaemia)
Neutrophils: 79.70 % (infection)
Lymphocytes :15.90% (infection)
Serum total protein : 5.20 g/dl
Serum albumin : 1.7 g/ dl
Serum ALT : 14
Serum sodium: 125 mEq/l
Serum potassium :3.37 mEq/l
Serum chloride: 90 mEq/l
 MEDICATIONS
Inj. Piptaz 4.5gm iv QSH (beta lactum antibiotics)
Inj. Amikacin 750mg iv OD (systemic aminoglycoside
antibiotics)
Inj. Dexa 4mg iv Q12H (corticosteroids)
Inj. Heparin 5000 U s/c bd (anticoagulant)
Nebulization with Duolin 2oo doses / pack Q8H
Nebulization with Budecort Q12h
Inj. Pan 40 mg OD (proton pump inhibitors)
T. Fluconazole 150 mg OD (antifungal drug)
Oxygen @ 2 l if Spo2 < 94%
 PERSONAL DATA 2
 NAME MR. VENKATESH
 AGE 65 YEARS
 SEX MALE
 MARITAL STATUS MARRIED
 RELIGION HINDU
 OCCUPATION SHOPKEEPER
 EDUCATIONAL LEVEL INTERMEDIATE (12th STANDARD)
 LANGUAGE SPOKEN KANNADA , HINDI
 MEDICAL DIAGNOSIS PNEUMONIA
 SURGICAL DIAGNOSIS NIL
 DATE OF ADMISSION 16/10/16
 DATE OF DISCHARGE 22/10/16
 DATE AND DURATION 17/10/16-19/10/16
OF CARE GIVEN
PRESENT HEALTH HISTORY-
Mr Venkatesh was admitted to the ward through OPD
with the complaints of fever since 2 days , productive
cough with purulent sputum since 5 days, dyspnoea since 2
days and pleuritic chest pain. After investigation chest X-
ray showed left lower opacity.
PAST HEALTH HISTORY-
He is known case of hypertension since 10 years and
he is taking amlodipine tablet (5mg) OD. He smokes at
least 5 cigarettes per day and he has been drinking alcohol
since 22 years.
INVESTIGATIONS DONE-

 SPUTUM – PRESENCE OF BACTERIA

 CHEST X-RAY – OPACITY OF LEFT LOWER LUNG
 HAEMOGLOBIN – 14.5 g/dl.
 WBC COUNT -15,500 per mcL(Infection)

MEDICATIONS GIVEN-
 INJECTION CEFTRIAXONE 2G BD
 TABLET LEVOFLOXACIN 500mg BD
 TABLET DOLO 650mg TID
 NEB WITH DUOLIN AND BUDEORT TID
 O2 SUPPLEMENTATION @ 2L/MINUTE if SPO2 IS <90%
 OXYGEN INSUFFICIENCY
INTRODUCTION

Oxygen insufficiency means “ deficient in oxygen”.

The normal range of oxygen in the external blood
should be 80-100 mm of Hg. For treating oxygen
insufficiency effectively, early diagnosis and correct
cause should be ruled out. The only management for
oxygen insufficiency is oxygen administration.
 DEFINITION

Oxygen insufficiency is a condition in which

the body as a whole or a region is deprived
of adequate oxygen supply. Oxygen
insufficiency is a failure to provide adequate
oxygen to cells of the body and to remove
excess carbon dioxide from them.
MEANING
The word oxygen comes from the Greek word
meaning “acid former “because most mineral
acids and carboxylic acids contains oxygen.

Oxygenation means the delivery of oxygen to the

body’s tissues and cells. It’s necessary to maintain
health and life.
 ANTOINE LA
VOISIER

THE ONE
WHO
COINED
THE TERM
OXYGEN
 HISTORICAL ASPECTS OF
OXYGEN
ANCIENT HINDU CONCEPT OF OXYGEN
The presence of lungs had been recognized in ancient Hindu
medicine. Both Charaka and Susrata the two famous
physicians/ surgeons of the vedic period
(500)BC,RECOGNIZED A ‘PRANA VAYU’, I.E LIFE AIR.

Charaka mentions the head , the chest, the ears, the tongue,
the mouth and the nose as the seat of ‘prana vayu’.Susrata
(1000)BC spoke of ‘ prana vayu’ as flowing in the mouth.
CHARAKA SUSRATA
 ANCIENT GREEK CONCEPT
In the 4th century BC, ARISTOTLE identified
few essential elements – earth ,air, fire and
water. The need for air remained well organized
,although its role was not identifiable.
MODERN HISTORY OF OXYGEN
:Paracelsus, a Swiss scientist had suggested in 1541 that
air contained a life sustaining substance.
Priestley called oxygen as the deep dephlogisticated air
Thomas beddoes used oxygen for the first time in early
1800 for treatment of medical disorders.
MODERN HISTORY OF OXYGEN
PARACELSUS PRIESTLY
ANATOMY OF
RESPIRATION
 Divisions of the Respiratory System

 Upper respiratory
tract (outside thorax)
 Nose
 Nasal Cavity
 Sinuses
 Pharynx

Larynx
 Divisions of the Respiratory System

 Lower respiratory
tract (within thorax)

 Trachea
 Bronchial Tree
 Lungs
 Structures of the Upper Respiratory Tract

 Nose - warms and moistens air

 Palantine bone separates
nasal cavity from mouth.
 Cleft palate - Palantine
bone does not form
correctly, difficulty in
swallowing and speaking.
 Septum - separates right
and left nostrils
 rich blood supply = nose
bleeds.
 Sinuses - 4 air containing
spaces – open or drain into
nose - (lowers weight of
skull).
 Structures of the Upper Respiratory Tract

 Pharynx - (throat)
 Base of skull to
esophagus
 3 divisions
 Nasopharynx - behind nose
to soft palate.
 Adenoids swell and
block.
 Oropharynx - behind
mouth, soft palate to hyoid
bone.
 tonsils
 Laryngopharynx - hyoid
bone to esophagus.
Larynx: these voice organ that connects the pharynx
and trachea .
 the major function of the larynx is the vocalization.
 protects the lower respiratory system from foreign
substance and facilitates coughing
It consist of the following
epiglottis,
glottis,
cricoids cartilage
arytenoid cartilage and
vocal cords.
 Structures of the Lower Respiratory Tract

 Trachea (windpipe)
 Larynx to bronchi
 Consists of smooth
cartilage and C
shaped rings of
cartilage.
 Tracheostomy -
cutting of an opening
in trachea to allow
breathing.
 Structures of the Lower Respiratory Tract

 Bronchi
 Tubes that branch off
trachea and enter into
lungs
 Ciliated
 Branches: Primary bronchi
—secondary bronchi—
tertiary bronchi—
bronchioles
 Bronchioles branch into
microscopic alveolar ducts.
Terminate into alveolar
sacs
 Gas exchange with blood
occurs in sacs.
Respiratory Zone

Figure 22.8a
Chapter 22, Respiratory System 26
Structures of the Lower Respiratory Tract
 Structures of the Lower Respiratory Tract

 Lungs
 Extend from
diaphragm to
clavicles
 Divided into lobes
by fissures.
 Visceral pleura
adheres to the
lungs.
 Pleurisy =
inflammation of the
pleural lining
 Respiratory Physiology

 Pulmonary Ventilation =
breathing
 Mechanism
 Movement of gases
through a pressure
gradient - high to low.
 When atmospheric
pressure (760 mmHg)
is greater than lung
pressure air flows in =
inspiration.
 When lung pressure is
greater than
atmospheric pressure
---- air flows out =
expiration.
Breathing
Breathing, or pulmonary ventilation, consists of two
phases
Inspiration – air flows into the lungs
Expiration – gases exit the lungs

Chapter 22, Respiratory System 30

Inspiration
The diaphragm and external intercostal muscles
(inspiratory muscles) contract and the rib cage rises
The lungs are stretched and intrapulmonary volume
increases
Intrapulmonary pressure drops below atmospheric
pressure (1 mm Hg)
Air flows into the lungs, down its pressure gradient,
until intrapleural pressure = atmospheric pressure

Chapter 22, Respiratory System 31

Inspiration

Figure 22.13.1
Chapter 22, Respiratory System 32
Expiration
Inspiratory muscles relax and the rib cage descends
due to gravity
Thoracic cavity volume decreases
Elastic lungs recoil passively and intrapulmonary
volume decreases
Intrapulmonary pressure rises above atmospheric
pressure (+1 mm Hg)
Gases flow out of the lungs down the pressure gradient
until intrapulmonary pressure is 0

Chapter 22, Respiratory System 33

Expiration

Chapter 22, Respiratory System 34

Figure 22.13.2
Pressure Relationships

Chapter 22, Respiratory System 35

Figure 22.12
http://people.eku.edu/ritchisong/301notes6.htm
 Volumes of Air Exchange

 Tidal volume - amount of air exhaled

normally after a typical inspiration. Normal
- about 500 ml
 Expiratory Reserve volume - additional
amount of air forcibly expired after tidal
expiration (1000 - 1200 ml).
 Inspiratory Reserve volume - (deep breath)
amount of air that can be forcibly inhaled
over and above normal.
 Residual volume - amount of air that stays
trapped in the alveoli (about 1.2 liters).
 Volumes of Air Exchange

 Vital capacity - the largest volume of air an

individual can move in and out of the lungs.
 Vital capacity = sum of IRV+TV+ERV
 Depends of many factors
 size of thoracic cavity
 posture
 volume of blood in lungs  congestive heart failure,
emphysema, disease, etc…
 Volumes of Air Exchange
 Eupnea - normal quiet breathing, 12-17
breaths per minute.
 Hyperapnea - increase in breathing to meet
an increased demand by body for oxygen.
 Hyperventilation - increase in pulmonary
ventilation in excess of the need for
oxygen.
 Hypoventilation - decrease in pulmonary
ventilation.
 Apnea - temporary cessation of breathing
at the end of normal expiration.
GAS EXCHANGE
DIFFUSION
Movement of gases from higher concentration to the
area of lower concentration.
Alveoli capillary layer enhances the diffusion to take
place during the ventilation without any difficult.
 OXYGEN TRANSPORT AND DELIVERY
Oxygen needs to be transported from the lungs
to the tissues and carbon dioxide must be
transported from the tissue to the lungs.
Normally most of the oxygen combines mostly
with the hemoglobin in the red blood cells
and its carried to tissues as oxyhemoglobin
PULMONARY CIRCULATION
PRINCIPLES RELEVANT TO OXYGEN
 
1. Oxygen is essential to life.
2. A person can survive only a few minutes without oxygen.
3. An insufficient supply of oxygen impairs functioning of al
body systems.
4. Irreparable brain damage may result from prolonged
periods of inadequate oxygen.
5. Cells of the cerebral cortex begin to die as soon as they are
deprived of oxygen.
6. Air at sea level containing approximately 20% of oxygen
and 0.04% carbon dioxide is sufficient to meet man’s
oxygen needs.
7.Carbon dioxide concentrations between 3 and 10 %
increase the rate and depth of respirations.
8.The body’s ability to meet its oxygen needs depends on
the adequacy of functioning of the cardiovascular and
the respiratory systems.
9.A patent airway is essential to normal respiratory
functioning.
10.The respiratory tract is lined with mucus secreting
epithelium.
11.Coughing, swallowing and sneezing are mechanisms by
which the body attempts to rid itself of foreign materials
in the respiratory tract.
12.Difficulty in breathing provokes anxiety.
CAUSES OF OXYGEN INSUFFICIENCY &
FACTORS AFFECTING
AT BIRTH
The fluid filled lungs
drain first
PHYSIOLOGICAL
FACTORS Click icon
to add pic
VARIOUS DISEASES ture
AFFECT
OXYGENATION
INCLUDING
RESPIRATORY
DISEASE LIKE
COPD,PNEUMONIA
CARDIOVASCULAR
DISEASE LIKE
CONGENITAL
CARDIAC
ANOMALIES
•Change in
ageing affects
respiratory
system.
•Infection,
physical or
emotional stress
DECREASED OXYGEN CARRYING CAPACITY
.Anemia and
inhalation of toxic
substances
decreases the oxygen
carrying capacity of
blood.
clients with
anemia have
complaints of
fatigue, decreased
activity tolerance
and increased
breathlessness and
pallor and an
increased heart rate.
BEHAVIOURAL
FACTORS
Whenever stress is
there, both
psychological &
physiological
changes can affect
the respiratory
system.
Person may
experience light
headedness,numb
ness,tingling of the
fingers, toes, and
around the mouth.
LIFESTYLE FACTORS
Physical activity or
exercise increase the
rate and depth of
respiration .
Smoking affects the
oxygenation status.
ENVIRONMENTAL FACTORS
Altitude heat, cold and
air pollution affect
oxygenation. The higher
the altitude lowers
is the pCo2 a patient
breaths. Air pollution
causes head ache,
chocking and
coughing even in
healthy people.
MEDICATION
Certain medication
including sedative ,
hypnotics(eg.diazepam)
and narcotics
including morphine
can cause
respiratory distresses
LIST OF COMMON DISEASES
WHERE OXYGEN INSUFFIENCY
OCCURS
SIGNS AND SYMPTOMS OF INADEQUATE
OXYGENATION
SIGN AND SYMPTOMS ONSET
CNS-
 Unexplained apprehension  Early
 Unexplained restlessness or  Early
irritability.
 Unexplained confusion or  Early or late
lethargy.
 Combativeness  Late
 Coma  Late
SIGNS AND SYMPTOMS ONSET
RESPIRATORY-
 Tachypnoea  Early
 Dyspnoea on exertion  Early
 Dyspnoea at rest  Early or late
 Use of accessory muscles  Late
 Retraction of interspaces on  Late
inspiration
 Pause for breath between  Late
sentences and words.
CARDIOVASCULAR-
 Tachycardia  Early
 Mild hypertension  Early
 Dysrhythmia  Early or late
 Hypotension  Late
SIGNS AND SYMPTOMS ONSET
RENAL SYSTEM-
 Decreased urinary output  Early or late.
(<0.5ml/kg)
INTEGUMENTARY SYSTEM-
 Diaphoresis  Early or late
 Clammy skin  Late
 Cyanosis  Late
OTHERS-
 Unexplained fatigue.  Early or late
NURSING MANAGEMENT
ASSESSMENT
PHYSICAL EXAMINATION
 Inspection
using inspection techniques the nurse performs the head to
toe observation of the client for the skin and the mucus
membrane , colour , general appearance, level of
consciousness, breathing pattern and chest wall movement.
Inspection includes observation of the
 nails for clubbing
the chest wall movement for retraction
 paradoxical breathing , asynchronous breathing and the
clients breathing pattern
clients effort during respiration, when especially distress or
flaring of noses, position distress
PALPATION
palpation of the chest provides assessment data's in several
areas
allows the nurse to feel for abnormal masses or any lumps in
the axilla and the breast tissue.
 Palpation of the extremities provides the data about the
peripheral circulation, the presence and the quality of the
peripheral pulses, skin temp, capillary refill and colour.
 Palpation should also include the feet and the legs to assess
the presence or absence of peripheral edema palpation of the
pulses in the neck and extremities is performed to assess the
arterial blood flow
 PERCUSSION
It allows the nurse to detect the presence of abnormal fluid
or air in the lungs.

 It is also used to determine the diaphragmatic excursion

it may reveal hyper resonance , dull percussion tone or
changes in the density of the lungs and the surrounding
tissues
 AUSCULTATION
It enables the nurse to identify the normal and abnormal
fluid in heart and lung sounds.
 Auscultation of the cardio vascular system should include
the assessment of normal s1 and s2 sounds, the presence of
abnormal s3 and s4 sounds (gallops), and murmurs or rubs.
Auscultation of lung sounds involves listening for the
movement of air throughout all lung fields ; anterior ,
posterior and lateral.

Adventitious breath sound appears when there is a

collapse of the lung segment, fluid in a lung segment or in
case of narrowing or any obstruction of the airway.

Auscultation also evaluates the clients response

intervention for improving their respiratory status.
Arterial blood gas analysis;
 ABG helps in the measurement of blood for patients arterial
oxygen
 Sputum studies;
sputum is obtained for analysis to identify the pathogenic
organism and to determine malignancy or hypersensitivity
which in turn is helpful to determine the causes for oxygen
insufficiency.
The sputum may also be collected through endotracheal
aspiration, bronchoscopal aspiration etc… the specimen are
usually collected in the early morning en and carbon dioxide
tensions
Chest X-rays and CT;
 To assess the fluids , tumor, foreign bodies and other
pathological conditions.
Bronchoscopic
It’s the direct inspection and examination of the larynx ,
trachea and bronchi through a fibrotic flexible
bronchoscope. The therapeutic bronchoscope are used to
Remove foreign from trachea bronchial tree
Remove secretions obstructing the tracheal esophageal tree
To destroy and excise tumor
.
Thoracentesis
 a sample of the pleural fluid is obtained by the thoracentesis
for both diagnostic and therapeutic purposes.
By, thoracentesis pleural fluid is studied for Grams stain
culture and sensitivity, acid fast staining and culture,
differential cell count, cytology, pH, specific gravity, total
protein .
Pulmonary angiography
pulmonary angiography is most commonly used to
investigate thrombotic disease of lungs, such as pulmonary
emboli and abnormalities of vascular trees.
It involves a rapid injection of a radio opaque agent into the
vasculature of the lungs for radiographic study of the
pulmonary vessels through femoral vein, or branches of
pulmonary artery and images are taken and analyzed
DIAGNOSTIC STUDIES
 PULMONARY FUNCTION TEST;
 These are used to assess the respiratory functions and to
determine the extent of dysfunction.
These are used to find the;
volume of the air in the lungs
speed and ease of air flow via airways
strength of the respiratory muscle
The PFT is performed by the technician using a spirometer
that has a volume collecting device attached to a recorder
that demonstrates the volume and time simultaneously.
NURSING MANAGEMENT

HEALTH PROMOTION

MOBILIZATION OF THE
OXYGEN
PULMONARY
THERAPY
SECRETIONS

CHEST POSTURAL
NEBULIZATION
PHYSIOTHERAPY DRINAGE
HAZARDS OF OXYGEN INHALATION

O2 ATELECTASIS
INFECTION
TOXICITY

O2
INDUCED
COMBUSTION
APNEA
DAMAGE

DRYING OF
THE MUCUS RETROLENTAL ASPHYXIA
MEMBRANE FIBROPLASIS
METHODS OF OXYGEN DELIVERY
Nasal cannula:
It is the most common inexpensive method used to
administer oxygen to client. It delivers a relatively low
concentration of oxygen (24% to 45%)at flow rate of 2-6
l/min.
But this is not in use nowadays. In these days nasal prongs
are used.
 Face mask:
The simple face mask delivers oxygen concentrations from 40% to
60% at flow rate of 5 to 8L/min respectively.
The face mask is sub divided into two types namely
REBREATHER MASK
NON REBREATHER MASK
Rebreather mask
In rebreather mask the oxygen reservoir bag that is
attached allows the client to rebreath the exhaled air in
conjunction with oxygen. Thus it increases
FiO2(fractional oxygen of inspired air) by recycling
expired oxygen.

Non rebreather mask

It delivers the highest oxygen concentration possible 95%
to 100% by means other than intubations or mechanical
ventilation, at liter flow of 10 to 15 L/min.
VENTURI MASK
It delivers oxygen concentration varying from 24% to 40% or
50%at flow rate of 4 to 5 lit /min. The venturi mask has wide
tubing and colour coded jet adaptors that correspond to a
precise oxygen concentration and flow rate
 Trans tracheal delivery
This is used for oxygen dependent clients. Oxygen is
delivered through a small, narrow plastic cannula
surgically inserted through the skin directly into
trachea .A collar around the neck holds the catheter in
place. Advantage-With the method client requires less
oxygen (0.5 to 2 L/ min) as all of theflow is delivered to
lungs directly.
Face tents: It can be used for clients who cannot
tolerate masks. These provide 30% to 50%
oxygen concentration at a flow rate of 4 to 8 L/
min.
VENTILATORS
Mechanical ventilation is a positive or negative
pressure breathing device that can maintain
ventilation and oxygen delivery for a prolonged period.
Types of ventilators
Negative pressure ventilation
This exerts the negative pressure on the external
chest; which in turn decreases the intra thoracic
pressure during inspiration and allows the air to flow
into the lungs., thereby filling its volume. These are
mainly used in clients with neuro muscular conditions
Advantage-easy to use and doesn’t require intubation
Disadvantage- unsuitable for patients who require
frequent ventilation changes
Positive pressure ventilation
These inflates the lungs by exerting pressure
on the airways, forcing the alveoli to expand
during inspiration.
Modes in ventilators
 ACV (Assist control ventilation)where assisted breaths are followed by
controlled breaths
 IMV-( Intermittent Mandatory Ventilation)are those which mixes
controlled breath and spontaneous breaths.
 PSV( Pressure Support Ventilation) this is where the patient has the
complete control over all the aspects of his/her breaths except the pressure
limits.
 CPAP- (Continuous positive airway pressure)- Spontaneous ventilation
with continuous positive airway pressure . The patient breaths
spontaneously through the ventilator at an elevated baseline pressure
throughout the breathing cycle.
 SIMV-(Synchronized intermittent mandatory ventilation)- Here patient
breath spontaneously while the ventilator delivers positive pressure breath
at interval that are predetermined but synchronized with the patient’s
breathing.
 APRV- it is a continuous positive pressure that set a timed interval to
release the applied pressure.
 HYPERBA
RIC OXYG
THERAPY EN

ADVANCE
OXYGEN
THERAPY
 OZONE T
ADVANCE HE RAPY

OXYGEN
THERAPY
NURSING DIAGNOSIS
NURSING DIAGNOSIS 1
Impaired gas exchange related to alveolar hypoventilation
as evidenced by headache on awakening , SaO2 less than
80% at rest .
Ineffective airway clearance related to airway obstruction
, ineffective cough , decreased airway humidity as
evidenced by presence of abnormal breath sounds.
Ineffective breathing pattern related to shortness of
breath evidenced by 30 b/min.
Imbalanced nutrition less than body requirement related
to poor appetite as evidenced by decreased body weight.
CONT…..1
Insomnia related to dyspnea as evidenced by frequent
awakening.
Activity intolerance related to fatigue as evidenced by
dependent on others.
Deficient knowledge related to self care strategies to
be performed at home .
Risk of infection related to corticosteroids therapy.
Assessment Nursing Outcome Implementati Evaluation
diagnosis on

Subjective Impaired gas patient is able •Respiratory Saturation was

data: exchange to improve in rate was 94%.
Patient related to gas exchange. assessed – 28
complains of alveolar b/min.
restless. hypoventilatio •Oxygen
Objective data n as evidenced saturation was
Dysnea was by headache checked-88%
noted. on •Assisted client
Saturation was awakening in sitting
88%. ,saturation position.
88% •Administered
oxygen 3l/min.
Assessment Nursing Outcome Implementat Evaluation
diagnosis ion

Subjective Ineffective Achivement of •General Airway

data: airway airway condition of clearance was
Client was clearance clearance. client was maintained.
coughing. related to assessed.
Objective airway •Auscultation
data: obstruction , was done.
Abnormal ineffective •Semi flowers
breath sound cough , position was
was decreased given.
heard(crackles airway •Fluids was
). humidity as given to drink.
evidenced by •Coughing
presence of technique was
abnormal taught.
breath sounds. •Nebulised
with duolin .
Assessment Nursing Outcome Implementat Evaluation
diagnosis ion
Subjective Ineffective Client Respiratory Breathing rate
data: breathing improves in rate was was 24b/m
Client pattern breathing monitored-
complaints of related to pattern to 28b/m.
difficulty in shortness of normal. Diaphragmati
breathing breath c and pursed
Objective evidenced by lip breathing
data: 30 b/min was taught.
Breath rate Spirometry
was 28b/m exercise was
taught.
Oxygen
3l/min was
administered
as per
ordered.
 NURSING DIAGNOSIS 2
 Ineffective airway clearance related to increased sputum
production .
 Hyperthermia related to infection.
 Acute pain related to inflammation of lung parenchyma and
persistent cough.
 Activity intolerance related to imbalance between oxygen supply
and demand and general weakness.
 Risk for deficient fluid volume related to excessive fluid loss .
 Risk for imbalanced nutrition pattern less than body requirement
related to increased metabolic needs secondary to fever and
infectious process.
 Deficient knowledge regarding condition, treatment and self care
related to lack of exposure.
ASSESSMENT DIAGNOSIS GOAL PLANNING EVALUATION

SUBJECTIVE DATA- Ineffective Patient  Assess the rate Patient

Patient complains airway maintains and depth of maintains
that he is having clearance patent airway. respirations and patent airway
breathing related to chest movement. to some extent
difficulty. increased  Elevate head of with the R.R of
OBJECTIVE DATA- sputum bed and change 20br/min.
Patient is having production as position
breathing evidenced by frequently.
difficulty as SPO2 increased  Educate and
is 88%, R.R is 28 respiratory assist with proper
br/min, presence rate. deep breathing
of cough, and coughing
cyanosis, exercise.
wheezing and  Provide warm
crackling sound. fluids at least
3000ml/day.
 Provide
nebulization and
treatment as per
physician’s order.
ASSESSMENT DIAGNOSIS GOAL PLANNING EVALUATION

SUBJECTIVE Hyperthermia Patient  Monitor vital The body

DATA- related to maintains the signs 4th hourly. temperature of
Patient infection as body  Provide loose the patient is
complains of evidenced by temperature. clothing. decreased to 99
having fever. increased body  Provide tepid degree
OBJECTIVE temperature. sponging. Fahrenheit.
DATA-  Encourage to
Patient is having take fluid
fever as orally.
evidenced by  Provide
• Warm skin adequate
• Increased ventilation.
Body  Provide iv
Temperature fluids as per
(101 degree physician’s
Fahrenheit) order.
• Presence of
dehydration .
ASSESSMENT DIAGNOSIS GOAL PLANNING EVALUATION

SUBJECTIVE Acute pain Patient • Provide Patient’s pain

DATA- related to maintains the comfort level is reduced
Patient inflammation of pain level. measures like to some extent.
complaints of lung position
having chest parenchyma and changes,
pain. persistent back rubs,
OBJECTIVE cough as massage ,
DATA- evidenced by etc.
Patient is having pain scale. • Encourage
pleuritic chest use of
pain as breathing
evidenced by exercises.
• Facial • Provide
expression divertional
• Verbalization measures like
• Pain scale quite music.
• Provide
analgesics as
per physician
order.