Acute and Chronic Respiratory Disorders Study Guide

**[Acute and Chronic Respiratory Disorders/Diseases]** **I. Pneumothorax** - **Etiology/Pathophysiology:** - Air or gas in the pleural space causes the lung to collapse. - This interrupts normal negative pressure, preventing full lung inflation. - **Tension pneumotho...

**[Acute and Chronic Respiratory Disorders/Diseases]** **I. Pneumothorax** - **Etiology/Pathophysiology:** - Air or gas in the pleural space causes the lung to collapse. - This interrupts normal negative pressure, preventing full lung inflation. - **Tension pneumothorax** is a life-threatening condition where air buildup under pressure interferes with heart and lung filling. - **Causes:** - Chest trauma (laceration of lung, puncture of pleura, fractured ribs). - Ruptured bleb (emphysema). - Injury from subclavian line insertion. - Spontaneous. - **Clinical Manifestations:** - May present with a recent chest injury. - Absent or decreased breath sounds on the affected side. - Sharp, pleuritic pain with dyspnea. - Diaphoresis and tachycardia. - Tachypnea. - Abnormal chest movement. - Sucking sounds with penetrating injury on inspiration. - Hypoxia. - Mediastinal shift to the unaffected side with compression of great vessels. - Hypotension due to decreased venous return. - **Assessment:** - *Subjective:* - Inquire about recent chest injury or severe coughing. - Patient reports chest pain, sudden shortness of breath, and anxiety. - *Objective:* - Unequal or absent breath sounds on the affected side. - Monitor for penetrating or blunt chest wounds and unequal chest movement. - Assess respiratory and cardiac rate and rhythm. - Monitor vital signs frequently. - Note sputum color, characteristics, and amount. - Hemoptysis and cough may be present. - **Diagnostic Tests:** - Chest x-ray reveals decreased lung expansion, fractured ribs, or mediastinal shift. - ABG will show decreased pH (acidotic) and PaO2 (hypoxemia), with increased PaCO2 (retention). - **Medical Management:** - Chest tube insertion with water-seal suction to allow for full lung expansion and healing. - Heimlich valve can be used temporarily. - **Needle thoracostomy** is performed for emergency decompression of a tension pneumothorax. - Large bore angiocath inserted in 2nd intercostal space, mid-clavicular line, on the affected side. - Chest tube must be inserted after needle decompression. - **Nursing Interventions:** - Maintain airway patency and adequate oxygenation. - Assess and document chest tube system patency. - Note color and amount of chest tube drainage. - Monitor vital signs frequently. - Maintain patient in high Fowler\'s to promote airway clearance and lung expansion. - Provide analgesics. - Assist with coughing and deep breathing. - Splint or support injured chest area. - Observe for respiratory compromise. - *Patient teaching*: rationale for chest tube and oxygen therapy, limit exposure to respiratory infections, avoid smoking, increase fluid intake, avoid fatigue, report recurrence. - **Nursing Diagnoses:** - Ineffective breathing pattern related to non-functioning lung. - Interventions: Assess respiratory rate and rhythm, provide chest tube care, facilitate optimal ventilation, suction as needed, and encourage adaptive breathing. - Fear related to feeling of air hunger. - Interventions: Assess feelings of fear, identify positive coping methods and support, determine support systems. **II. Lung Cancer** - **Etiology/Pathophysiology:** - Leading cause of cancer death. - Tumors may be primary or metastatic (colon and kidney are common sites). - Approximately 87% of lung tumors are linked to smoking. - Risk increases with smoking duration and amount. - Other causes include passive smoking, occupational exposures, and air pollution. - Mortality depends on cancer type and tumor size at diagnosis. - **Types of Lung Cancer:** - Small cell lung cancer (20% of cases). - Non-small cell lung cancer (30-32%), including adenocarcinoma. - Squamous cell carcinoma (30% of cases). - Large cell (9% of cases). - **Clinical Manifestations:** - *Peripheral lesions*: few symptoms, may cause pleural effusion and severe pain. - *Central lesions*: obstruction or erosion of bronchus, hemoptysis, dyspnea, fever, chills, wheezing, and phrenic nerve involvement (paralysis of the diaphragm). - *Metastasis*: weight loss and may involve the liver, bone, esophagus, brain, and pericardium. - **Assessment:** - *Subjective:* chronic hoarseness, chronic cough, smoking history, weight loss, and fatigue. - *Objective:* hemoptysis, shortness of breath, unilateral wheeze, pleural effusion, edema of face and neck (superior vena cava syndrome), friction rub, clubbing of fingers, and pericardial effusion. - **Diagnostic Tests:** - Chest x-ray, CT scan (more precise), MRI, bronchoscopy, fine needle aspiration, biopsy, mediastinoscopy, and scalene lymph node biopsy. - **Medical Management:** - One-third of patients are inoperable at diagnosis, another third during exploratory thoracotomy. - Surgical treatment: pneumonectomy (removal of entire lung), lobectomy, segmental resection, and video-assisted thorascopic surgery. - Radiation and chemotherapy, often with surgery. - Chemotherapy and radiation for SCLC. - **Nursing Interventions:** - Improve quality of life, help patient and family cope with diagnosis. - Monitor side effects of anti-neoplastics. - Plan activities to reduce exertion and conserve patient\'s energy. - Assist with nutrition, monitor for recurrence. - Relieve pain with analgesics. - Encourage smoking cessation. - Identify community resources. - **Nursing Diagnoses:** - Ineffective airway clearance related to lung surgery. - Interventions: Facilitate optimal breathing, elevate the head of the bed, encourage early ambulation, assist with position changes, promote cough and deep breathing, assess breath sounds. - Fear related to cancer, treatment, and prognosis. - Interventions: Explain treatments, listen to the patient, encourage verbalization of feelings, assist in identifying support services, and monitor for signs of worthlessness, anxiety and powerlessness. - **Prognosis:** Only 15.9% of lung cancer patients live 5 years or longer. **III. Pulmonary Edema** - **Etiology/Pathophysiology:** - Accumulation of serous fluid in interstitial lung tissue and alveoli. - Caused by severe left ventricular failure, inhalation of irritating gases, rapid IV fluid administration, or barbiturate/opiate overdose. - Increased pulmonary capillary pressure forces fluid into the alveoli. - Severely affects gas diffusion, leading to respiratory distress. - Acute and can lead to death if untreated. - **Clinical Manifestations:** - Dyspnea and labored respirations. - Tachypnea, tachycardia. - Hypoxia, cyanosis. - Pink, frothy sputum. - Restlessness and agitation. - **Assessment:** - *Subjective:* dyspnea and feelings of impending death. - *Objective:* - Signs of respiratory distress (nasal flaring, sternal retractions, rapid/snoring respirations). - Hypertension, tachycardia, restlessness, and disorientation. - Wheezing and crackles on auscultation. - Weight gain (fluid retention), decreased urinary output. - Productive cough with frothy, pink sputum. - **Diagnostic Tests:** - Chest x-ray: fluid infiltrates, pleural effusion, cardiomegaly. - ABG: hypoxia, PaCO2 varies (respiratory alkalosis initially, then acidosis). - **Medical Management:** - Oxygen therapy, may require intubation for positive pressure ventilation. - *Medications*: - Lasix (reduces edema, dilates pulmonary vasculature). - Morphine sulfate (reduces anxiety, respiratory rate, venous return, dilates vascular beds). - IV Nipride (vasodilator, reduces pulmonary congestion). - Digoxin (for underlying cardiac dysfunction). - **Nursing Interventions:** - Frequent respiratory status assessment (breath sounds, oxygenation via pulse oximetry and ABG). - Strict I&O. - Oxygen therapy (Venturi mask, possible mechanical ventilation). - Maintain proper positioning for gas exchange (high Fowler\'s). - Maintain IV access for medication administration. - Heplock or TKO all fluids. - *Patient teaching:* effective breathing techniques, medications, low-sodium diet, and fluid restriction. - **Prognosis:** guarded if not treated emergently. **IV. Pulmonary Embolus (PE)** - **Etiology/Pathophysiology:** - Passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches causing obstruction. - Risk factors: thrombophlebitis, recent surgery, pregnancy/childbirth, contraceptives, CHF, obesity, immobilization from fracture. - Venous stasis, wall injury, and increased coagulability cause thrombus formation (usually in deep veins of lower extremities). - Thrombus travels through the venous circulation, to the right side of the heart, and lodges in the pulmonary artery. - Obstruction hinders oxygenation of blood, leads to atelectasis, increased pulmonary vascular resistance, and arterial hypoxia. - **Clinical Manifestations:** - Sudden, sharp, constant, non-radiating chest pain worsening on inspiration. - Acute, unexplained dyspnea. - Tachypnea. - Hemoptysis. - Diminished lung sounds and wheezes. - Elevated temperature. - Hypotension and diaphoresis. - Bronchoconstriction, atelectasis, pulmonary edema, and decreased surfactant. - **Assessment:** - *Subjective*: degree of dyspnea, chest pain, and risk factors. - *Objective:* pleuritic chest pain, cough, tachypnea, tachycardia, signs of hypotension, crackles or decreased breath sounds, pleural friction rub, and anxiety. - **Diagnostic Tests:** - ABG: hypoxia, respiratory alkalosis initially, then acidosis. - Chest x-ray: usually normal initially, may show infiltrates or enlarged pulmonary artery after 24 hours. - CT angiogram (replacing V/Q scan). - V/Q scan (smaller facilities). - Pulmonary arteriogram (leading test for detecting PE). - D-dimer (detects fibrin degradation products, indicates a thrombus). - Venous ultrasound (confirms DVT). - **Medical Management:** - *Medications:* - Anticoagulants (Heparin, Lovenox, Coumadin) to prevent further clot formation. - Thrombolytics (to dissolve PE). - Filter device in the inferior vena cava to block emboli. - Embolectomy (surgical removal of large thrombus). - **Nursing Interventions:** - Assess sensorium for worsening hypoxemia. - Monitor cardiorespiratory status (vital signs, pulse oximetry, capillary refill, peripheral pulses). - Elevate HOB 30 degrees. - Oxygen therapy. - Monitor pulses in affected lower extremity and calf measurements. - DVT treatment: bedrest, TED hose. - Assess for bleeding from anticoagulation. - *Patient teaching:* avoid venous stasis, proper application of antiembolism hose, medication information (low molecular weight heparin, Coumadin), reasons to return to the physician. - **Nursing Diagnoses** - Impaired gas exchange related to alteration in pulmonary vasculature. - Interventions: Assess sensorium and vital signs, elevate head of bed, administer oxygen, monitor ABG\'s. - Ineffective perfusion, related to risk of prolonged bleeding or hemorrhage secondary to anticoagulation therapy. - Interventions: Monitor vital signs, check stool, urine, sputum and vomitus for occult blood. - **Prognosis:** Untreated PE carries 30% mortality, reduced to 2-8% with early diagnosis and treatment. **V. Acute Respiratory Distress Syndrome (ARDS)** - **Etiology/Pathophysiology:** - Also called Non-cardiogenic Pulmonary Edema. - Syndrome of intrapulmonary shunting, hypoxemia, reduced lung compliance, and lung damage. - *Three Phases:* - **Acute phase:** uncontrolled inflammation, damage to pulmonary capillary endothelium, platelet aggregation, intravascular thrombi, release of serotonin. - **Proliferative phase:** pulmonary edema resolves, fibrin matrix (hyaline membrane) forms, hypoxemia worsens. - **Fibrotic phase:** fibrosis obliterates alveoli, bronchioles, interstitium, decreased functional residual capacity, severe right-to-left shunting, inflammation, and narrowed airways. - *Causes:* viral or bacterial pneumonia, chest trauma, aspiration, inhalation injury, near drowning, fat emboli, sepsis, shock, overdoses, renal failure, and pancreatitis. - Altered alveolar capillary membrane permeability, causing leakage of plasma and blood into interstitial space, resulting in pulmonary edema and hypoxia. - **Clinical Manifestations:** - Manifests within 12 to 24 hours post-injury. - Respiratory distress with altered breath sounds within 5 to 10 days. - Altered sensorium due to elevated PaCO2 and decreased PaO2. - Tachycardia, hypotension, and decreased urinary output. - **Assessment:** - *Subjective*: obtain information on recent illness. - *Objective*: does not respond to supplemental oxygen therapy, assess respiratory rate, rhythm, and effort, signs of dyspnea, auscultate lungs for crackles and wheezing, assess level of consciousness, pulse, and temperature, and elevation of peak inspiratory pressure if intubated. - **Diagnostic Tests:** - Pulmonary function tests (ability for gases to diffuse across the alveoli). - Arterial blood gases: decreased PaO2 and HCO3, increased PaCO2, and decreased pH. - Chest X-ray: thickened bronchial margins, diffuse bilateral infiltrates (white out). - **Medical Management:** - Supportive treatment: maintain adequate oxygenation, treat the cause. - Mechanical ventilation, Positive end-expiratory pressure (PEEP) to open alveoli and improve oxygenation. - *Medications:* Diuretics, Morphine sulfate (sedation), Digoxin (cardiac function), Antibiotics. - Nitric oxide (experimental treatment, vasodilation). - **Nursing Interventions:** - Provide adequate oxygenation, ventilation, and treat multi-system responses to ARDS. - Monitor respiratory status, vital signs, position for optimal ventilation. - Prone positioning (for more than 12 hours decreases mortality, facilitates secretion removal, and improves oxygenation). - Skin integrity with prone position- Place hydrocolloid or silicone dressing on chest, pelvis, elbows, and knees. - **Nursing Diagnoses** - Impaired gas exchange, related to tachypnea. - Interventions: Monitor ABGs, check pulse oximetry, administer oxygen, report changes in vital signs and level of consciousness. - Ineffective breathing pattern, related to respiratory distress. - Interventions: Assess respiratory rate, rhythm and effort, facilitate optimal ventilation by proper positioning, maintain airway patency. **VI. Acute Respiratory Failure** - **Etiology/Pathophysiology:** - Inability of the respiratory system to provide oxygenation and/or remove carbon dioxide. - Ventilation failure (hypercapnia and hypoxemia) or oxygen failure (hypoxemia). - Occurs rapidly. - Intrapulmonary shunting. - Diffusion defects. - Low cardiac output, and low hemoglobin. - **Assessment:** - *Subjective:* change in mental status. - *Objective:* altered LOC (anxiety, restlessness, confusion, lethargy), shallow respirations, respiratory fatigue. - **Diagnostic Tests:** - Pulmonary Function tests, chest x-ray, CBC/BMP (hemoglobin/hematocrit, electrolytes), ABG, and pulse oximetry. - **Interventions:** - Treat the cause. - Maintain patent airway (intubation and mechanical ventilation). - Optimize oxygen delivery. - Provide adequate rest. - Prevent complications. - **Concerns, Symptoms, and Nursing Actions** - *Respiratory muscle fatigue*: diaphoresis, nasal flaring, tachycardia, abdominal paradox, muscle retractions, central cyanosis. - Actions: Improve O2 delivery, administer O2, ensure adequate cardiac output and blood pressure, correct low hemoglobin, administer bronchodilators, decrease O2 demand, provide rest, reduce fever, relieve pain and anxiety, position patient, prepare for intubation and mechanical ventilation. - *Cerebral hypoxia and CO2 narcosis*: Lethargy, somnolence, coma, respiratory acidosis. - Actions: Maintain airway patency, prepare for intubation and mechanical ventilation. **VII. Chronic Obstructive Pulmonary Disorder (COPD)** - **Emphysema** - **Etiology/Pathophysiology:** - Symptoms develop in 40s, disability in 50s and 60s. - Changes in alveolar walls and capillaries. - Abnormal, permanent enlargement of alveoli, destruction of their walls. - Overlap between chronic bronchitis and emphysema. - Inflamed bronchi, bronchioles, and alveoli; air trapped, alveolar distention. - Alveoli rupture and scar, losing elasticity; decreased oxygen, increased carbon dioxide. - Primarily from cigarette smoking. - Risk factors: same as chronic bronchitis plus heredity (deficiency of ATT). - May lead to cor pulmonale. - **Clinical Manifestations:** - Exertional dyspnea. - Sputum minimal at onset, copious later. - Accessory muscle use, pursed-lip breathing, barrel chest. - Wheezing, chronic weight loss with emaciation. - **Assessment:** - *Subjective:* onset of symptoms (dyspnea, cough, sputum), history of smoking, family history. - *Objective:* tachycardia, tachypnea, orthopnea, peripheral cyanosis, clubbing of fingers, barrel chest. - **Diagnostic Tests:** - PFT: decreased total lung capacity, increased residual volume and compliance, increased airway resistance. - ABG: decreased PaO2, increased PaCO2, low-normal or elevated pH, and increased HCO3. - Chest x-ray: hyperinflation, widened intercostal spaces, flattened diaphragm. - Labs: Alpha1-antitrypsin (ATT) assay, CBC (elevated erythrocytes, hemoglobin, hematocrit). - **Medical Management:** - Long-term management with home oxygen and chest physiotherapy, mechanical ventilation during acute exacerbations. - *Medications*: Bronchodilators (beta-adrenergic agonists, theophyllines, anticholinergics), antibiotics, corticosteroids (during exacerbations), diuretics, oxygen therapy, and anti-anxiety agents. - **Nursing Interventions:** - Decrease anxiety, promote optimal air exchange. - Elevate the head of the bed. - Low flow oxygen (1-2 liters nasal cannula). - *Patient Teaching*: nutrition, smoking cessation, infection control, and relaxation techniques. - *Nutrition* : Increased protein and calorie needs, divided into 5-6 small meals, fluids between meals. - *Smoking Cessation:* Nicotine replacement, support groups. - *Infection control*: yearly flu vaccine and pneumovax every 5 years, avoid contact with respiratory infections. - **Prognosis:** Irreversible; 3rd leading cause of death in the US. - **Nursing Diagnoses:** - Ineffective airway clearance related to narrowed bronchioles. - Interventions: Assess ability to mobilize secretions, encourage coughing and deep breathing, elevate HOB, suction as needed, assist with respiratory treatments, auscultate lungs. - Activity intolerance, related to imbalance between oxygen demand. - Interventions: Organize care so periods of activity are interspersed with rest, advise patient to rest 30 minutes before meals, assist with ADLs and exercises, assess respiratory response to activity. - **Chronic Bronchitis** - **Etiology/Pathophysiology:** - Recurrent chronic productive cough for at least three months for two years. - Physical or chemical irritants or recurrent lung infections. - Smoking is the most common cause. - Impaired cilia, mucous gland hypertrophy, increased susceptibility to infection. - Chronic infection leads to scarring causing obstruction, increased airway resistance, bronchospasm, hypoxia, and hypercapnia. - **Clinical Manifestations** - Productive cough (most pronounced in the morning), dyspnea, accessory muscle use. - Later signs: cyanosis, right ventricle failure (cor pulmonale), reddish-blue skin from polycythemia and dependent edema. - **Assessment** - *Subjective*: detailed smoking history, irritant exposure, family history of respiratory disease. - *Objective*: cough characteristics, sputum amount, severity of dyspnea, wheezing, anxiety, vital signs (tachypnea, tachycardia, hyperthermia). - **Diagnostic tests** - CBC: polycythemia and elevated WBCs. - ABG: respiratory acidosis (may be normal), hypoxia, hypercapnia. - Pulse oximetry. - PFT: decreased flow on expiration, increased airway resistance and residual volumes. - **Medical Management** - Minimize disease progression and facilitate optimal air exchange. - *Medications*: Beta-adrenergic agonists, anticholinergics, corticosteroids, mucolytics, and antibiotics. - **Nursing Interventions** - Secretion management, adequate hydration, suction as needed. - Low-flow oxygen, frequent oral hygiene, rest periods. - High calorie, high protein diet. - **Nursing Diagnoses** - Ineffective breathing pattern related to retained pulmonary secretions. - Interventions: Assess dyspnea, teach effective breathing techniques, suction as needed. - Fatigue, related to increased respiratory effort. - Interventions: Assess fatigue, provide treatment in a calm manner, encourage adequate rest, identify support systems. **VIII. Asthma** - **Etiology/Pathophysiology:** - Episodic increased tracheal and bronchial responsiveness. - Classified as extrinsic (allergens) or intrinsic (upper respiratory infection, emotional upsets). - Re-occurrence of attacks is influenced by mental or physical fatigue, and GERD. - Narrowing of airways resolves spontaneously or with treatment. - Altered immune response or increased airway resistance and altered air exchange. - Acute attacks are caused by the antigen-antibody reaction which releases histamine. - Three primary mechanisms: recurrent reversible airway obstruction, increased capillary permeability, acute inflammatory response. - **Clinical Manifestations:** - Mild asthma: dyspnea on exertion and wheezing (controlled with meds). - Acute attack: tachypnea, tachycardia, diaphoresis, expiratory wheezing, accessory muscle use, nasal flaring, and anxiety (often at night). - Status asthmaticus: severe, unrelenting form unresponsive to drugs, leads to exhaustion and respiratory failure. - **Assessment:** - *Subjective:* quality of life, medications, asthma triggers, and anxiety. - *Objective*: signs of respiratory distress and impending failure, cyanosis, amount of respiratory effort, frequent vitals, auscultate for wheezing and decreased air movement, patient assuming the tripod or hunched position. - **Diagnostic Tests:** - ABG (hypoxia and hypercarbia). - PFT (airway reversibility, peak flow). - Chest x-ray (air trapping and hyperinflation). - Sputum culture. - CBC (increased eosinophils). - Theophylline level. - **Medical Management:** - *Maintenance therapy* (prevent or minimize symptoms): Bronchodilators (long-acting beta 2 agonists), inhaled corticosteroids, leukotriene inhibitors. - *Acute or rescue therapy*: Bronchodilators (short-acting beta 2 agonists), corticosteroids, epinephrine, IV aminophylline. - Oxygen should be started immediately in an acute attack. - Peak flow meter helps monitor symptom severity. - Identification of triggers. - **Nursing Interventions:** - **Nursing Diagnoses** - Ineffective breathing pattern, related to narrow airway. - Interventions: Assess ventilation and respiratory effort, monitor signs of dyspnea, position to facilitate optimal ventilation, administer medications, assist with respiratory treatments, provide care in calm manner, attempt to minimize exposure to triggers, maintain adequate hydration. - Health maintenance, ineffective, related to possible allergens in the home. - Interventions: Assist in identifying allergens, facilitate allergy testing, teach the importance of allergy avoidance, medication usage, use of peak flow meter, reasons to call physician. - **Prognosis:** Death rate has increased; status asthmaticus is fatal if not reversed. **IX. Bronchiectasis** - **Clinical Manifestations:** - Signs and symptoms usually after respiratory tract infection. - Coughing when arising and lying down. - Copious foul-smelling sputum. - Fatigue, weakness, loss of appetite. - Late signs: dyspnea, cyanosis, and clubbing. - **Etiology** - Irreversible chronic dilation of bronchi that destroys lung elasticity. - Follows repeated lung infections. - Secondary to failure of lung tissue defenses (cystic fibrosis, foreign body, or tumor). - Complication of inflammation altering pulmonary structures. - **Assessment:** - *Subjective*: dyspnea, weight loss, fever. - *Objective*: signs of dyspnea, cyanosis, clubbing of fingers, paroxysmal coughing, foul-smelling sputum, fatigue, crackles and wheezing in the lower lobes, prolonged expiratory phase, hemoptysis, increased hematocrit. - **Diagnostic Tests:** - Chest x-ray (normal or inflammation/mediastinal shift). - High-resolution CT scan. - Sputum cultures. - PFTs (decreased forced expiratory volume). - **Medical Management:** - Low-flow oxygen. - Chest physiotherapy. - Adequate hydration. - *Medications*: Mucolytic agents, bronchodilators, and antibiotics. - Lobectomy if conservative measures fail. - **Nursing Interventions:** - Secretion management, adequate hydration, cool mist vaporizer/humidifier, suction as needed. - Assess vital signs and lung sounds frequently. - Turn, cough, and deep breathe frequently. - Assist with chest physiotherapy. - Maintain on low-flow oxygen, frequent oral hygiene, and rest periods. - **Nursing Diagnoses** - Airway clearance, ineffective, related to retained pulmonary secretions. - Interventions: Assess ability to mobilize secretions, encourage postural drainage, cough, and suction, maintain hydration, and administer medications. - Physical mobility, impaired, related to decreased exercise tolerance. - Interventions: Assess activity tolerance, promote rest, gradual increase of activity, problem-solve on energy conserving techniques. **X. Nursing Process for Patients with Respiratory Disorders** - **Role of the Nurse:** - Participate in planning care, recommend revisions, follow prioritizations, use clinical pathways. - **Assessment:** - Level of consciousness, vital signs, lung sounds, subjective reports (SOB, dyspnea, cough). - Observe for signs of respiratory distress (flaring nostrils, retractions, asymmetric chest expansion). - **Patient Problems:** - Anxiousness, inability to clear airway, inability to maintain adequate breathing pattern, inability to tolerate activity, inefficient oxygenation, and insufficient nutrition. - **Expected Outcomes and Planning:** - Effective breathing patterns, adequate airway clearance, adequate tissue oxygenation, realistic attitude toward treatment, improved activity tolerance, and maintenance of a patent airway. - **Implementation:** - Maintaining optimal health, improving activity tolerance, perform ADLs without dyspnea. - **Evaluation:** - Assess patient exercise tolerance and auscultate lungs.