Predisposing Factors Age Sex

Precipitating Factors
pain Anxiety, Psychosis Fever Stroke Meningitis Tumor Anemia High Altitude Salicylate Toxicity Pregnancy, progesterone Pulmonary diseases: pneumonia, pulmonary edema, Pnuemothorax.

Low partial Pressure of the Oxygen in Arterial Blood (Pao2) Peripheral Chemoreceptors Rate of Firing Increases Stimulation of the Respiratory Center in the Medulla Hyperventilation

Hypocapnia

Increase Blood pH

Hypoventilation

Renal buffering

Retention of CO2

H+ Retention

HCO3 Excretion

Blood pH returns to Normal

dizziness, light headedness, agitation, and tingling or numbing around the mouth and in the fingers and hands. Muscle twitching, spasms, and weakness. Seizures, irregular heart beats, and tetany

Nursing diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes

1. Monitor respiratory rate, depth, and effort. 2. Auscultate breath sounds. 3. Note character of cough mechanism 4. Assess level of consciuosness. 5. Monitor VS. 6. Evaluate pulse oxymetry. 7. Elevate head of bed. 8. Maintain adequate I/O. 9. Administer meds. 10. Monitor client in therapeutic and adverse reaction of drugs. 11. Encourage frequent position changes.

Nursing diagnosis: Risk for falls related to dizziness 1. Assess factors for fall risk. 2. Assess Mental status changes. 3. Assess Disease-related symptoms. 4. Ensure appropriate room lighting. 5. Encourage to wear shoes /slippers. 6. Provide chair w/ firm seat and arms. 7. Encourage to participate in a regular exercise. 8. Educate about risk factors for fall in home. 9. Place bright, nonskid strips on the edge of stair treads. 10.Ensure rugs are securely fastened to floors. 11.Rearrange furniture. 12.Increase lighting at the top and bottom of stairs.

Nursing diagnosis: Activity Intolerance related to muscle weakness. 1. Determine patient's perception of causes of activity intolerance. 2. Assess level of mobility. 3. Assess nutritional status. 4. Assess potential for physical injury. 5. Assess need for ambulation aids. 6. Monitor sleep pattern. 7. Observe and document response to activity. 8. Assess emotional response. 9. Establish guidelines and goals of activities. 10. Encourage adequate rest periods. 11. Refrain performing nonessential procedures. 12. Anticipate patient's needs. 13. Assist with ADLs. 14. Assist patient to plan activities. 15. Encourage verbalization of feelings regarding limitations. 16. Progress activity gradually. 17. Encourage ROM exercises. 18. Teach appropriate use of environmental aids.