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Predisposing FactorsAgeSex

Precipitating Factors pain

Anxiety, Psychosis

Fever

Stroke

Meningitis

Tumor

Anemia

High Altitude

Salicylate Toxicity

Pregnancy, progesterone

Pulmonary diseases:

pneumonia, pulmonary edema,

Pnuemothorax.

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Low partial Pressure of the Oxygen in

Arterial Blood (Pao2)

Peripheral Chemoreceptors Rate ofFiring Increases

Stimulation of the Respiratory Center in

the Medulla

Hyperventilation

Hypocapnia

Increase Blood pH

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Hypoventilation Renal buffering

Retention of CO2 H+ Retention

Blood pH returns to Normal

HCO3

Excretion

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

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Nursing diagnosis: Impaired Gas Exchange related

to alveolar-capillary membrane changes1. 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.

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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.

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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.