NCP Impaired Gas Exhange Related To Alveolar Wall Destruction EMPHYSEMA
NCP Impaired Gas Exhange Related To Alveolar Wall Destruction EMPHYSEMA
NCP Impaired Gas Exhange Related To Alveolar Wall Destruction EMPHYSEMA
COLLEGE OF NURSING
La Paz, Iloilo City
Nursing Nursing
Clustered Cues Rationale Outcome Criteria Rationale Evaluation
Diagnosis Interventions
Impaired gas Impaired gas The client will be Assess for altered Patients will
exchange related exchange is excess or able to maintain breathing pattern: adapt their
to the deficit in oxygenation optimal gas breathing
destruction of and/or carbon dioxide exchange by a. increased patterns over
alveolar walls elimination at the proper work of time to facilitate
alveoli-capillary positioning, breathing gas exchange.
membrane. breathing b. Abnormal
exercises, rate, rhythm,
Emphysema is a
hydration, oxygen and depth of
chronic obstructive
administration respiration
pulmonary disease
and c. abnormal
(COPD) that is
bronchodilators chest
characterized by
as evidenced by excursions
abnormal,
permanent
Posture, upright
enlargement of the air
Assess generalized positioning and
spaces past the
appearance. mental alertness
terminal bronchioles,
cue the nurse to
which results in the
the severity of the
destruction of
COPD
respiratory walls.
exacerbation.
In emphysema, the
Assess for Restlessness is an
affected terminal
restlessness, early sign of
bronchioles contain
headache, hypoxia. Lethargy
mucous plugs that,
confusion, dizziness, and somnolence
when they are
reduced ability to are late signs.
enlarged, eventually
follow instructions.
result in the loss of Hypoxia or
elasticity of the lung hypercarbia may
parenchyma, thus Monitor vital signs. cause initial
causing difficulty hypertension with
in the expiratory restlessness and
phase of respiration. progress to
The alveolar walls are hypotension and
destroyed by somnolence.
abnormal levels
of enzymes Dyspnea often
(proteases) that break increases anxiety,
down respiratory Assess level of and anxiety
walls. Gas exchange is anxiety and fear. increases oxygen
impaired by the use by tissues.
reduced surface area Anxiety may be
that results from the an indication of
destruction of alveolar worsening
walls. hypoxemia.
Promote more
Emphysema is a effective breathing
disorder in which the pattern for better
alveolar walls are gas exchange:
destroyed. This a. Upright and
destruction leads to a. Instruct in semi-
permanent positioning for fowler’s
overdistention of air optimal positions
spaces. Air passages breathing. favor better
are obstructed as a lung
result of these expansion;
changes. Research has the
shown that the diaphragm
enzymes protease and is pushed
elastase can attack downward.
and destroy the If the
connective tissue of patient is
the lung. Emphysema bedridden,
may result from a turning
breakdown in the from side to
lungs normal defense side at least
mechanism against 2 hours
these enzymes. promotes
b. Teach and better
Difficult expiration in demonstrate aeration of
emphysema is the pursed-lip all lung
result of the breathing. lobes.
destruction of the
walls between the b. This
alveoli and septa c. Teach NA to encourages
collapse, and loss of use abdominal more
elastic recoil. As the breathing. complete
alveoli and septa exhalation.
collapse, pockets of d. Teach the
air form between the therapeutic c. This assists
alveolar spaces and use of splint in a more
within the lung when forceful
parenchyma. This coughing exhalation.
process leads to
increased ventilatory d. To protect
dead space from areas Collaborative: site injury
that do not participate and
in gas or blood Monitor ABGs and minimize
exchange. oxygen saturation. pain from
coughing