1. Patient Clinical Assessment
- Subjective Data: Patient reports severe shortness of breath upon minimal exertion, fatigue, and inability to clear tenacious sputum.
- Objective Data: Barrel chest, prolonged expiratory phase, audible wheezing bilaterally, SpO2 86%, ABG reveals mild respiratory acidosis (pH 7.32, PaCO2 52 mmHg, PaO2 58 mmHg).
2. Priority NANDA-I Diagnoses
- Ineffective Airway Clearance related to bronchospasm and copious tenacious secretions as evidenced by ineffective cough and wheezing.
- Impaired Gas Exchange related to alveolar-capillary membrane changes and air trapping as evidenced by hypoxemia (SpO2 86%) and hypercapnia.
3. SMART Goals & Expected Outcomes
- Patient will maintain an SpO2 of 88%–92% via low-flow nasal cannula (1–2 L/min) within 1 hour of admission.
- Patient will demonstrate effective huff coughing and pursed-lip breathing techniques prior to discharge.
4. Nursing Interventions & Evidence-Based Rationales
| Intervention | Rationale (Evidence-Based) |
|---|---|
| Position patient in High-Fowler's position or orthopneic position. | Promotes maximum diaphragmatic excursion and improves lung volume expansion. |
| Administer titrated oxygen therapy (1-2 L/min) targeting SpO2 88-92%. | Avoids suppression of hypoxic respiratory drive while preventing severe tissue hypoxia. |
| Teach Pursed-Lip and Diaphragmatic Breathing. | Creates positive expiratory pressure, keeping bronchioles open and preventing air trapping. |