Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Defining Characteristics:
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
Suggested NIC Labels
Nursing Interventions and Rationales
1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns.
Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia.
2. Auscultate breath sounds q __ h(rs).
Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia.
3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy.
Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000).
4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available.
An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.
5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes.
Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993).
6. If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion.
Anxiety can exacerbate dyspnea, causing the client to enter into a dyspneic panic state (Gift, Moore, Soeken, 1992; Bruera et al, 2000). The nurse's presence, reassurance, and help in controlling the client's breathing can be very beneficial (Truesdell, 2000).
7. Demonstrate and encourage the client to use pursed-lip breathing.
Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Breslin, 1992). Pursed-lip breathing can result in increased exercise performance (Casciarai et al, 1981), and it empowers the client to self-manage dyspnic incidences (Truesdell, 2000).
8. Position client with head of bed elevated, in a semi-Fowler's position as tolerated.
Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs.
9. If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema.
Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992).
10. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position, which increases oxygenation as indicated by pulse oximetry (or if client has pulmonary catheter, venous oxygen saturation). Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into a supine position and evaluate oxygen status.
Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi, Dracup, 1998).
11. If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated.
A study demonstrated that use of the reverse Trendelenburg position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994; Winslow, 1996).
12. Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma.
Partial pressure of arterial oxygen has been shown to increase in the prone position, possibly because of greater contraction of the diaphragm and increased function of ventral lung regions (Douglas et al, 1977; Lasater-Erhard, 1995; Curley, 1999). Prone positioining improves hypoxemia significantly (Dupont et al, 2000). In one study clients with multisystem trauma had serious iatrogenic injuries with prone positioning, including wound dehiscence, chest wall pressure necrosis, and a cardiac arrest (Offner et al, 2000).
13. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated.
Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). The tripid position can be helpful during times of dypnea (Dunn, 2001).
14. Help client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles as tolerated.
This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective
NOTE: If client has excessive fluid in respiratory system, see interventions for Ineffective Airway clearance.
15. Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously.
Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia.
16. Schedule nursing care to provide rest and minimize fatigue.
The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.
17. Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy.
A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy.
18. Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve.
If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation.
19. Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, Stubbing, 1996).
20. Monitor nutritional status. Refer client for a dietary consult if needed.
Many clients with emphysema are malnourished. Improved nutrition can help improve inspiratory muscle function (Meeks et al, 1999).
21. If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation.
Pulmonary rehabilitation programs that include desensitization to dyspnea and guided mastery with monitored exercise are preferable. Pulmonary rehabilitation has been shown to improve exercise capacity, ability to walk, and sense of well-being (Fishman, 1994; American Thoracic Society, 1999; Janssens, 2000). The processes of desensitization and guided mastery for control of dyspnea have helped clients learn to be in control of their condition and have increased the amount of activity they can tolerate (Carrieri-Kohlman et al, 1993).
22. Refer client to pulmonary rehabilitation team if client has chronic respiratory disease.
This team is multidisciplinary, and working together can help increase exercise capacity, decrease dyspnea, improve quality of life, and decrease admissions to the hospital (Celli, 1998).
NOTE: If client becomes ventilator-dependent, see care plan for Impaired spontaneous Ventilation.
Geriatric
1. Use central nervous system depressants carefully to avoid decreasing respiration rate.
An elderly client is prone to respiratory depression.
2. Maintain low-flow oxygen therapy.
An elderly client is susceptible to oxygen-induced respiratory depression.
3. Encourage client to stop smoking.
There are substantial health benefits for elderly clients who stop smoking (Foyt, 1992).
Home Care Interventions
1. Assess the home environment for irritants that impair gas exchange. Help the client to adjust home environment as necessary (e.g., installing air filter to decrease presence of dust).
2. Refer client to occupational therapy as necessary to assist with adapting to home environment and energy conservation.
3. Assist client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, proximity to noxious gas fumes such as chlorine bleach).
Irritants in the environment decrease the client's effectiveness in accessing oxygen during breathing.
4. Instruct client to limit exposure to persons with respiratory infections.
5. Instruct family in complications of disease and importance of maintaining medical regimen, including when to call physician.
6. Assess nutritional status. Instruct client to eat several small meals daily and to use dietary supplements as necessary.
Clients with decreased oxygenation have little energy to use for eating and will avoid meals. Malnutrition significantly affects the aerobic capacity of muscle and exercise tolerance in clients with chronic obstructive pulmonary disease (COPD) (Palange et al, 1995). When nutritional status is clearly improved, it is accompanied by improvements in strength of the respiratory muscles and, in some studies, increased distance of walking (Larson, Leidy, 1998).
7. Refer client for home health aide services as necessary to assist with activities of daily living (ADLs).
Clients with decreased oxygenation have decreased energy to carry out personal and role activities.
8. Assess family role changes and coping ability. Refer client to medical social services as appropriate for assistance in adjusting to chronic illness.
Inability to maintain pre-illness level of social involvement leads to frustration and anger in the client and may create a threat to the family unit. In one study, clients with chronic lung problems were described as negative, helpless, confused, and socially obstreperous by their family members (Leidy, Traver, 1996).
9. Refer to outpatient pulmonary rehabilitation program, or a home-based training program for COPD.
Outpatient rehabilitation programs can achieve worthwhile benefits, including decreased perception of dypnea, increased walking distance, and less fatigue, with benefits that persist for a period of 2 years (Glell R et al, 2000). A simple home-based program of exercise training can achieve improvement in exercise tolerance, dyspnea, and quality of life for COPD patients (Hernandez et al, 2000). In mild COPD, a weight-training program was shown to result in increased strength and increased exercise tolerance (Clark et al, 2000).
10. Support family of client with chronic illness.
Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.
Client/Family Teaching
1. Teach client these techniques to use during acute dypneic episodes:
Cold air temperatures cause constriction of the blood vessels and increased moisture, impairing the client's ability to absorb oxygen.
3. Teach clients to keep humidity levels in their homes between 40% and 50%, using a humidifier or dehumidifier as needed.
Both high humidity and low humidity can affect the ability of the COPD client to breathe comfortably (Dunn, 2001).
4. Teach client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
5. Teach the importance of not smoking. Be aggressive in approach, and ask client to set a date for smoking cessation. Recommend nicotine replacement therapy (nicotine patch or gum). Refer client to smoking cessation programs. Encourage clients who relapse to keep trying to quit.
All health care clinicians should be aggressive in helping smokers quit (Agency for Health Care Policy Research, 1996).
6. Instruct family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). If need for oxygen is chronic, encourage use of a portable system. Explain advantages of transtracheal oxygen delivery systems. Encourage client to use oxygen as ordered.
Clients with portable oxygen therapy spent more time outside and walked futher than people with fixed delivery systems (Vergeret, Brambilla, Mounier, 1989). Clients with transtracheal oxygen delivery systems were more independent than those with fixed delivery systems and had increased morale (Bloom et al, 1989; Larson, Leidy, 1998). Clients who used oxygen for longer periods had decreased mortality (Pierson, 2000).
7. Teach client relaxation therapy techniques to help reduce stress responses and panic attacks resulting from dyspnea.
Relaxation therapy includes progressive muscle relaxation, autogenic techniques, visualization, and diaphragmatic breathing. This therapy can help to modify the symptoms of dyspnea and help the client deal with feelings associated with the chronic disease (Jerman, Haggerty, 1993).
Defining Characteristics:
- Visual disturbances;
- decreased carbon dioxide;
- dyspnea;
- abnormal arterial blood gases;
- hypoxia;
- irritability;
- somnolence;
- restlessness;
- hypercapnia;
- tachycardia;
- cyanosis (in neonates only);
- abnormal skin color (pale, dusky);
- hypoxemia;
- hypercarbia;
- headache on awakening;
- abnormal rate, rhythm, depth of breathing;
- diaphoresis;
- abnormal arterial pH;
- nasal flaring
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Respiratory Status: Gas Exchange
- Respiratory Status: Ventilation
- Tissue Perfusion: Pulmonary
- Vital Signs Status
- Electrolyte and Acid-Base Balance
- Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters
- Maintains clear lung fields and remains free of signs of respiratory distress
- Verbalizes understanding of oxygen and other therapeutic interventions
Suggested NIC Labels
- Airway Management
- Oxygen Therapy
- Respiratory Monitoring
- Acid-Base Management
Nursing Interventions and Rationales
1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns.
Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia.
2. Auscultate breath sounds q __ h(rs).
Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia.
3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy.
Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000).
4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available.
An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.
5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes.
Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993).
6. If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion.
Anxiety can exacerbate dyspnea, causing the client to enter into a dyspneic panic state (Gift, Moore, Soeken, 1992; Bruera et al, 2000). The nurse's presence, reassurance, and help in controlling the client's breathing can be very beneficial (Truesdell, 2000).
7. Demonstrate and encourage the client to use pursed-lip breathing.
Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Breslin, 1992). Pursed-lip breathing can result in increased exercise performance (Casciarai et al, 1981), and it empowers the client to self-manage dyspnic incidences (Truesdell, 2000).
8. Position client with head of bed elevated, in a semi-Fowler's position as tolerated.
Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs.
9. If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema.
Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992).
10. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position, which increases oxygenation as indicated by pulse oximetry (or if client has pulmonary catheter, venous oxygen saturation). Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into a supine position and evaluate oxygen status.
Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi, Dracup, 1998).
11. If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated.
A study demonstrated that use of the reverse Trendelenburg position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994; Winslow, 1996).
12. Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma.
Partial pressure of arterial oxygen has been shown to increase in the prone position, possibly because of greater contraction of the diaphragm and increased function of ventral lung regions (Douglas et al, 1977; Lasater-Erhard, 1995; Curley, 1999). Prone positioining improves hypoxemia significantly (Dupont et al, 2000). In one study clients with multisystem trauma had serious iatrogenic injuries with prone positioning, including wound dehiscence, chest wall pressure necrosis, and a cardiac arrest (Offner et al, 2000).
13. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated.
Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). The tripid position can be helpful during times of dypnea (Dunn, 2001).
14. Help client deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles as tolerated.
This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective
NOTE: If client has excessive fluid in respiratory system, see interventions for Ineffective Airway clearance.
15. Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously.
Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia.
16. Schedule nursing care to provide rest and minimize fatigue.
The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.
17. Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy.
A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy.
18. Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve.
If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation.
19. Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, Stubbing, 1996).
20. Monitor nutritional status. Refer client for a dietary consult if needed.
Many clients with emphysema are malnourished. Improved nutrition can help improve inspiratory muscle function (Meeks et al, 1999).
21. If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation.
Pulmonary rehabilitation programs that include desensitization to dyspnea and guided mastery with monitored exercise are preferable. Pulmonary rehabilitation has been shown to improve exercise capacity, ability to walk, and sense of well-being (Fishman, 1994; American Thoracic Society, 1999; Janssens, 2000). The processes of desensitization and guided mastery for control of dyspnea have helped clients learn to be in control of their condition and have increased the amount of activity they can tolerate (Carrieri-Kohlman et al, 1993).
22. Refer client to pulmonary rehabilitation team if client has chronic respiratory disease.
This team is multidisciplinary, and working together can help increase exercise capacity, decrease dyspnea, improve quality of life, and decrease admissions to the hospital (Celli, 1998).
NOTE: If client becomes ventilator-dependent, see care plan for Impaired spontaneous Ventilation.
Geriatric
1. Use central nervous system depressants carefully to avoid decreasing respiration rate.
An elderly client is prone to respiratory depression.
2. Maintain low-flow oxygen therapy.
An elderly client is susceptible to oxygen-induced respiratory depression.
3. Encourage client to stop smoking.
There are substantial health benefits for elderly clients who stop smoking (Foyt, 1992).
Home Care Interventions
1. Assess the home environment for irritants that impair gas exchange. Help the client to adjust home environment as necessary (e.g., installing air filter to decrease presence of dust).
2. Refer client to occupational therapy as necessary to assist with adapting to home environment and energy conservation.
3. Assist client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, proximity to noxious gas fumes such as chlorine bleach).
Irritants in the environment decrease the client's effectiveness in accessing oxygen during breathing.
4. Instruct client to limit exposure to persons with respiratory infections.
5. Instruct family in complications of disease and importance of maintaining medical regimen, including when to call physician.
6. Assess nutritional status. Instruct client to eat several small meals daily and to use dietary supplements as necessary.
Clients with decreased oxygenation have little energy to use for eating and will avoid meals. Malnutrition significantly affects the aerobic capacity of muscle and exercise tolerance in clients with chronic obstructive pulmonary disease (COPD) (Palange et al, 1995). When nutritional status is clearly improved, it is accompanied by improvements in strength of the respiratory muscles and, in some studies, increased distance of walking (Larson, Leidy, 1998).
7. Refer client for home health aide services as necessary to assist with activities of daily living (ADLs).
Clients with decreased oxygenation have decreased energy to carry out personal and role activities.
8. Assess family role changes and coping ability. Refer client to medical social services as appropriate for assistance in adjusting to chronic illness.
Inability to maintain pre-illness level of social involvement leads to frustration and anger in the client and may create a threat to the family unit. In one study, clients with chronic lung problems were described as negative, helpless, confused, and socially obstreperous by their family members (Leidy, Traver, 1996).
9. Refer to outpatient pulmonary rehabilitation program, or a home-based training program for COPD.
Outpatient rehabilitation programs can achieve worthwhile benefits, including decreased perception of dypnea, increased walking distance, and less fatigue, with benefits that persist for a period of 2 years (Glell R et al, 2000). A simple home-based program of exercise training can achieve improvement in exercise tolerance, dyspnea, and quality of life for COPD patients (Hernandez et al, 2000). In mild COPD, a weight-training program was shown to result in increased strength and increased exercise tolerance (Clark et al, 2000).
10. Support family of client with chronic illness.
Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.
Client/Family Teaching
1. Teach client these techniques to use during acute dypneic episodes:
- Pursed-lip breathing and controlled diaphragmatic breathing: Have client watch pulse oximetry to note improvement in oxygenation with breathing techniques. Controlled breathing techniques can help control anxiety and decrease panic and dyspnea (Celli, 1998; Dunn, 2001).
- Progressive muscle relaxation with or without guided imagery. Progressive relaxation eases the workload of muscles that are not being used to breathe, reducing the body's oxygen requirement (Dunn, 2001).
- Assistive breathing technique: Fold arms just below ribcage and push into belly while exhaling, then release during inhalation; repeat process until breathing becomes more controlled. This technique can help push the diaphragm up and force out the trapped air that was causing the feeling of pressure (Dunn, 2001).
Cold air temperatures cause constriction of the blood vessels and increased moisture, impairing the client's ability to absorb oxygen.
3. Teach clients to keep humidity levels in their homes between 40% and 50%, using a humidifier or dehumidifier as needed.
Both high humidity and low humidity can affect the ability of the COPD client to breathe comfortably (Dunn, 2001).
4. Teach client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
5. Teach the importance of not smoking. Be aggressive in approach, and ask client to set a date for smoking cessation. Recommend nicotine replacement therapy (nicotine patch or gum). Refer client to smoking cessation programs. Encourage clients who relapse to keep trying to quit.
All health care clinicians should be aggressive in helping smokers quit (Agency for Health Care Policy Research, 1996).
6. Instruct family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). If need for oxygen is chronic, encourage use of a portable system. Explain advantages of transtracheal oxygen delivery systems. Encourage client to use oxygen as ordered.
Clients with portable oxygen therapy spent more time outside and walked futher than people with fixed delivery systems (Vergeret, Brambilla, Mounier, 1989). Clients with transtracheal oxygen delivery systems were more independent than those with fixed delivery systems and had increased morale (Bloom et al, 1989; Larson, Leidy, 1998). Clients who used oxygen for longer periods had decreased mortality (Pierson, 2000).
7. Teach client relaxation therapy techniques to help reduce stress responses and panic attacks resulting from dyspnea.
Relaxation therapy includes progressive muscle relaxation, autogenic techniques, visualization, and diaphragmatic breathing. This therapy can help to modify the symptoms of dyspnea and help the client deal with feelings associated with the chronic disease (Jerman, Haggerty, 1993).
21 komentar:
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Question for those of you that work with young children: what is the best affordable Pulse Oximeter and probe for infants / babies?
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Dr Itua cure my HIV, I have been a ARV Consumption for 10 years. i have been in pains until i came across Dr Itua on blogs site.I emailed him about my details of my HIV and my location i explained every thing to him and he told me that there is nothing to be scared of that he will cured me, he gave me guarantee,He ask me to pay for items fees so when i'm cured I will show gratitude I did and giving testimony of his healing herbs is what I'm going to do for the rest of you out there having HIV and other disease can see the good work of Dr Itua.I received his herbal medicine through EMS Courier service who delivered to my post office within 5 working days.Dr Itua is an honest man and I appreciate him for his good work.My GrandMa called him to appreciate him and rest of my friends did too,Is a joy to me that I'm free of taking Pills and having that fat belle is a nightmare.you will understand what i'm talking about if you have same problem I was having then not now though.I'm free and healthy Big Thanks To Dr Itua Herbal Center.I have his calendar too that he recently sent me,He Cure all kind disease Like,Cancer,Herpes,Fibromyalgia,Hiv,Hepatitis B,Liver/Kidney Inflamatory,Epilepsy,Infertility,Fibroid,Diabetes,Dercum,Copd ,and also Bring back Ex Lover Back..Here his Contact .drituaherbalcenter@gmail.com Or Whats_app Number +2348149277967
I have long felt a special connection with herbal medicine. First, it's natural, Charlie attended the same small college in Southern California - Claremont Men's College - although he dropped out of school to enroll in the Julliard School of Performing Arts in New York. York. Had he been to Claremont, he would have been senior the year I started there; I often thought that was the reason he was gone when he discovered that I had herpes. So, my life was lonely, all day, I could not stand the pain of the outbreak, and then Tasha introduced me to Dr. Itua who uses her herbal medicines to cure her two weeks of consumption. I place an order for him and he hands it to my post office, then I pick it up and use it for two weeks. All my wound is completely healed no more epidemic. I tell you honestly that this man is a great man, I trust him Herbal medicine so much that I share this to show my gratitude and also to let sick people know that there is hope with Dr. Itua. Herbal Phytotherapy.Dr Itua Contact Email.drituaherbalcenter@gmail.com/ info@drituaherbalcenter.com. Whatsapp ... 2348149277967
He cures.
Herpes,
Breast Cancer
Brain Cancer
CEREBRAL VASCULAR ACCIDENT.
Hepatitis
Lung Cancer
H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE 5.
HIV
Cervical Cancer
Colo-rectal Cancer
Blood Cancer
SYPHILIS.
Diabetes
Liver / Inflammatory kidney
Epilepsy
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MY TESTIMONY ABOUT HOW DR IMOLOA HERBAL CREAM ENLARGE MY PENIS FROM 4 INCHES TO 8 INCHES
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PENIS ENLARGEMENT, BREAST ENLARGEMENT, DIABETES 1/2,HIV/AIDS,HERPES,CANCER,PREMATURE EJACULATION,WEAK ERECTION,ERECTILE DYSFUNCTION ,LOW SPERM COUNT PREGNANCY HERBAL MEDICINE HIGH BLOOD PRESSURE LOW SPERM COUNT LYME DISEASE many more.. Contact Him At drimolaherbalmademedicine@gmail.com or whatssapp--+2347081986098
I am not sure of the cause of COPD emphysema in my case. I smoked pack a day for 12 or 13 years, but quit 40 years ago. I have been an outdoor person all my adult life. Coughing started last summer producing thick mucus, greenish tint to clear. I tried prednisone and antibiotics, but no change. X-rays are negative, heart lungs and blood and serum chemistries all are normal. I have lung calcification from childhood bout with histoplasmosis. I am 75 years old and retired.My current doctor directed me to totalcureherbsfoundation .c om which I purchase the COPD herbal remedies from them ,they are located in Johannesburg, the herbal treatment has effectively reduce all my symptoms totally, am waiting to complete the 15 weeks usage because they guaranteed me total cure.
I started on COPD Herbal treatment from Ultimate Health Home, the treatment worked incredibly for my lungs condition. I used the herbal treatment for almost 4 months, it reversed my COPD. My severe shortness of breath, dry cough, chest tightness gradually disappeared. Reach Ultimate Health Home via their email at ultimatehealthhome@gmail.com . I can breath much better and It feels comfortable!
I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
liver already present. I started on antiviral medications which
reduced the viral load initially. After a couple of years the virus
became resistant. I started on HEPATITIS B Herbal treatment from
ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
treatment totally reversed the virus. I did another blood test after
the 6 months long treatment and tested negative to the virus. Amazing
treatment! This treatment is a breakthrough for all HBV carriers.
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I grew up with asthma; I suffered sinus and respiratory infections my entire life. I started smoking at 16. When I was in my early 40s, my asthma was becoming increasingly worse. I was diagnosed with COPD at age 47. I am now 55. I quit smoking four years ago. The disease does not improve. My good days were far, i was scared that i wont survive it but i was so lucky to receive a herbal products from my step father who bought it while coming from South Africa for Rugby league, this herbal remedies saved me from this disease, at first it helps fight the symptoms of diseases and i was seeing good outcome, i had to use it for 13 weeks just as they Dr was prescribed and i was totally cure of asthma and COPD, (multivitamincare org ) do not hesitate to purchase from them they deliver across worldwide.
Hi, there. I am Tom Neil and I wish to describe how life had been for my younger brother living with schizophrenia and how he had been permanently able to subdue this debilitating disease via a naturopathic, herbal method.
Maicon - my kid brother was twenty years old when he was brought to the emergency room by the campus police of the college from which he had been suspended several months ago. A professor had called and reported that he had walked into his classroom, accused him of taking his tuition money, and refused to leave.
Although he had much academic success as a teenager, his behavior had become increasingly odd during the past year. He quit seeing his friends and no longer seemed to care about his appearance or social pursuits. He began wearing the same clothes each day and seldom bathed. He lived with several family members but rarely spoke to any of them. When he did talk to them, he said he had found clues that his college was just a front for an organized crime operation. He had been suspended from college because of missing many classes. My sister said that she had often seen him mumbling quietly to himself and at times he seemed to be talking to people who were not there. He would emerge from my room and ask my family to be quiet even when they were not making any noise.
My father and sister told the staff that Maicon's great-grandmother had had a serious illness and had lived for 30 years in a state hospital, which they believed was a mental hospital. Our mother left the family when Maicon was very young. She has been out of touch with us, and they thought she might have been treated for mental health problems.
Maicon agreed to sign himself into the psychiatric unit for treatment. The whole family except I had agreed to have Maicon transferred to a mental asylum. I knew inwardly there was still some plausible means by which my kid brother could overcome this condition. I knew botanical means of treatment will be more favorable than any other type of treatment, and as such, I had taken a keen interest in the research of naturopathic alternative measures suitable for the treatment of schizophrenia. I had pleaded for some little patience from the family in the delay of the transfer, I was looking forward to proving a point to the entire family, of a positive botanical remedy for this condition.
It was during my ceaseless search on the internet I had been fortunate enough to come across Dr. Utu Herbal Cure: an African herbalist and witch doctor whose professional works had majored on the eradication of certain viral conditions, especially schizophrenia, ( improving the memory capacity positively), via a traditional, naturopathic process and distinguished diet plan. It was by the administration of this herbal specialist that my brother had been able to improve his condition for better.
Before the naturopathic remedy - Maicon's story had reflected a common case, in which a high-functioning young adult goes through a major decline in day-to-day skills. Although family and friends may feel this is a loss of the person they knew, the illness can be treated and a good outcome is possible.
My brother Maicon is just like many other patients out there suffering from this disease. Although he was able to overcome this condition via a naturopathic herbal remedy administered by this African herbal physician and saved completely thus, rekindling the lost joy which had been experienced by the family members.
I wish to use this opportunity to reach across to anyone who may happen to be diagnosed with this disastrous condition to spread the hope of an everlasting herbal remedy that is capable of imposing a permanent end to this disease.
For more information concerning this naturopathic herbal remedy, feel free to contact this African herbal practitioner via email:
drutuherbalcure@gmail.com
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