Download Impaired Gas Exchange

Melissa Wise Nursing 217
Planning/Implementation/Evaluation
Patient Room: 14 B
Med/Surg Nursing Diagnosis: Impaired gas exchange r/t inflammatory process of the lungs and ineffective cardiac pump AEB O2 Sat 93%
with Venti mask at 31% oxygen.
Long-Term Goal: Patient will regain adequate gas exchange.
Outcome Criteria
Interventions
1. Patients BP will
be 120/80, HR will
be 60-80 bpm
regular rate and
rhythm, Respirations
12-20 unlabored and
O2 saturation > 95%
as assessed q4h
and PRN
1. Assess vitals
q4h and PRN
2. Patient’s lung
sounds will trend
to clear as
assessed q4h and
PRN
2. Assess lung
sounds q4h and
PRN
3. Patient will remain
alert & respond
appropriately q4h
and PRN
3. Monitor LOC
q4h and PRN
4. Patients chest xray will be clear,
showing no patchy
opaqueness as
ordered
4. Monitor chest xray results as
ordered
Rationale
Evaluation
1. Assessing vital signs frequently will give the nurse an implication of the patient’s current health status
and to quickly notice any change in patient’s condition. Hypoxia symptoms occur when inadequate
oxygen reaches the tissues of the body. Increases in heart rate, respiratory rate and blood pressure are
early signs that the body is not getting enough oxygen. O2 saturation is a quick noninvasive way of
telling us if enough gas exchange is occurring. RR will increase to get the patient to inhale more O2,
HR will increase as the heart attempts to pump blood faster to vital organs to get them more oxygen,
and BP will increase due to vasoconstriction of vessels as the body goes into fight or flight mode. Early
signs of hypoxia are a good indicator that the patient has impaired gas exchange. Patient has impaired
gas exchange because of the inflammatory process of the lungs and an ineffective cardiac pump,
therefore it is important to monitor vitals to catch any changes in a timely manner.
P&P 445;821-823
2. Normal lung sounds should be clear over the posterior and lateral thoraxes. Three types of breath
sounds are expected in various parts of the thorax: vesicular, Bronchovesicular, and bronchial.
Adventitious lung sounds such as wheezing, crackles/Rales are a good indicator that the patient may be
having impaired gas exchange. Changes in lung sounds may reveal the etiology of impaired gas
exchange. Patient was diagnosed with pneumonia and pulmonary edema, Assessing lung sounds
will help determine the effectiveness of the medications that are being administered. (Lasix,
Spironalactone, and Levoquin should all show an improvement in lung sounds) Also on
admission, patients BNP was 863, an increase in adventitious lung sounds would indicate
worsening heart failure.
NCP 437
3. A change in mentation such as increased confusion, restlessness, or decrease in level of
consciousness is an early signs of hypoxia meaning that the patient’s brain is not getting enough
oxygen. It is necessary that the brain receives enough oxygen to keep the patient alert and oriented as
well as to carry out vital body functions to keep the patient alive. By assessing for these things at every
interaction the nurse can detect earlier where there is a problem with gas exchange and plan
interventions to prevent any further decline. Patient was admitted for SOB and admitted to “blacking
out” in his car which are both indicators that he has impaired gas exchange.
4. A chest x-ray is a painless, noninvasive test that takes a picture of the structures inside your thoracic
cavity such as your heart and lungs. It is used to screen, diagnose, and evaluate changes in the
respiratory system. A chest x-ray was important for my patient because he was admitted with
syncope, his BNP on admission was 863, and his lung sounds had coarse crackles in the bil
bases. Having a chest x-ray would help differentiate whether it is a cardiac and respiratory
issue that is causing his impaired gas exchange. His CXR showed patchy opaqueness and helped
to diagnose him with pneumonia. It would be important for the physician to order another chest x-ray
prior to discharge to see how the pneumonia is clearing up seeing as the patients O2 sat is only 93%
while receiving O2 via venti mask at 31%.
Lewis pg 513
1. Outcome partially met
Patients BP was 108/65 HR
was 73 and regular,
Respirations 20 unlabored, and
O2 sat was 93% with the venti
mask on at 31%. I did
encourage the patient to take
deep breaths and to use his
incentive spirometer
Plan is ongoing
2. Outcome not met.
Lung sounds were clear in BIL
upper lobes, but there were
course crackles in both bases. I
encouraged TCDB and
incentive spirometer
Plan is ongoing
3. Outcome met
Patient remained A&O x3
during every interaction
Plan is ongoing
4. Outcome not met
Patient’s chest x-ray showed
patchy opaqueness, likely
pneumonia. He is still receiving
antibiotics. Also encouraged
TCDB and IS
Plan is ongoing
Melissa Wise Nursing 217
5. Patients WBC
will trend
downward to 5,000
- 10,000 within 24
hours of
administration of
Levofloxacin.
5. Dependent
Administer
Levofloxacin in
D5W 750 mg
IVPB q48h per
MD order
5. Levofloxacin (Levaquin) is a fluoroquinolone (anti-infective) used in the treatment of bacterial
infections of the respiratory tract, including pneumonia. It inhibits bacterial DNA synthesis by
inhibiting DNA gyrase enzyme, causing the death of susceptible bacteria. The time it takes to
completely resolve the infection depends on the organism and the site of the infection. The
patients CXR showed patchy opaqueness in the LLL and possibly the RLL. He also had
coarse crackles in the bilateral bases as a result of the combination of infection and
pulmonary edema, and his WBC count on admission was 19.2. If the anti-infective is
working properly you should see a decrease in his WBC count. As the infection subsides there
will be a decrease in the inflammatory process in his lungs which will help improve his gas
exchange.
Davis Drug Guide online
6. Patients WBC
6.Independent
6. A Complete Blood Count (CBC) is used to assess the patient for anemia, infection,
will trend
Monitor CBC
inflammation among other things. A CBC is a series of different tests used to evaluate the
downward toward
daily
blood and cellular components of the red blood cells, white blood cells and the platelets. The
5,000-10,000
white blood cell count is the total number of the five types of leukocytes present in 1mm3 of
within 24 hours of
blood. The leukocyte count is a general indicator of infection, tissue necrosis, or inflammation.
administration of
The elevated value of WBCs occurs in response to infection and is usually directly
Levofloxacin.
proportionate to the degree of bacterial invasion. The normal WBC range at this agency is
5,000-10,000. The patient was diagnosed with pneumonia, therefore it is important to monitor
his WBC count to ensure that the antibiotic that is being administered is actually working and
show a decline in his WBC count.
Lab and Diagnostic tests 222-224
7. Patient will have 7. Dependent
7. Administering supplemental O2 increases the partial pressure of O2 in inspired air. The
an O2 sat of 92% Administer O2 2- goals for O2 therapy are to reduce the work of breathing, maintain the PaO2, reduce the
on RA as
6 L/min to keep
workload of the heart, and to keep SaO2 greater that 92%. O2 therapy will supply the patient
2
assessed q4h
O sats > 95 %
with adequate oxygen help maximize the oxygen carrying ability of the blood. Patient has
and PRN
coarse crackles in the bilateral bases of his lungs. Gas exchange at the alveolar level can be
compromised because of copious excretions as well as the inflammatory process.
Lewis p 612; 618-619
8. Patient will have 8.Independent
8. Elevating the HOB while the patient is laying down facilitates breathing by maintaining
an O2 sat of 95%- Keep HOB
abdominal organs away from diaphragm. This allows for better contraction and expansion of
100% with
elevated while
diaphragm allowing for better lung expansion leading to increase in alveolar gas exchange.
optimal lung
in bed
Patient was diagnosed with pneumonia and showing signs of impaired gas exchange, therefore
expansion while
it is important to implement interventions to help him have optimal lung expansion until the
in bed.
infection is resolved and the inflammatory process has stopped.
5. Outcome not met
Patient’s WBC count has
decreased from 19.2 on
admission to 14.6, but is still
not WNL. Patient is still
receiving antibiotic q48h
Plan is ongoing
6. Outcome not met
Patient’s WBC count has
decreased from 19.2 on
admission to 14.6, but is still
not WNL. Patient is still
receiving antibiotic q48h
Plan is ongoing
7. Outcome not met
Patient received continuous
oxygen at 31% per venti
mask and O2 sat was only
93%
Plan is ongoing
8. Outcome not met
Patient did have the HOB
elevated while he was in
bed, however his O2 sat was
93% with the venti mask on
at 31%. I encouraged deep
breathing and IS
Plan is ongoing
Melissa Wise Nursing 217
9. Patients BNP
will be < 100
pg/mL as
assessed on
admission
9. Assess
serum BNP on
admit
10. Patient’s
secretions will be
thin and easily
expectorated 2-4
hours after
administration of
Guaifenesin
10. Dependent
Administer
Guaifenesin 600
mg PO bid per
MD orders
11. Patients lung
sounds will trend
to clear clear by
day 2
11. Dependent
Administer
Furosemide 20
mg PO qday
12. Patients lung
sounds will trend
to clear clear by
day 2
12. Administer
Spironolactone
25 mg PO qday
9. Natriuretic peptides (atrial natriuretic peptide [ANP] and b-type natriuretic peptide
[BNP]) are hormones produced by the heart muscle that promote venous and arterial
vasodilation (thus reducing afterload and preload).The release of BNP is triggered by
increased pressure, especially in the left ventricle. BNP levels have been shown to be
significantly increased in patients with HF. Left-sided failure results from left ventricular
dysfunction, which prevents normal blood flow and causes blood to back up into the left
atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid
extravasation from the pulmonary capillary bed into the interstitium and then the alveoli,
which manifests as pulmonary congestion and edema. On admission patients BNP level
was 863 pg/mL (normal BNP should be < 100 pg/mL) which indicates that his heart was
not working as effectively as it should. It is important to monitor BNP along with a chest
x-ray to determine if the patients impaired gas exchange is related to a cardiac issue or
respiratory issues. Lewis p 800-805
10. Guaifenesin is an expectorant that is administered to decrease viscosity of secretions by
increasing respiratory tract fluid. It should be taken with a full glass of water to help further
decrease viscosity of secretion. An expectorant will help clear secretions made from the
inflammatory response as it relates to the patients diagnosis of pneumonia. This will help
improve gas exchange by decreasing fluid in the lungs allowing for increased lung expansion.
Per other nursing assessments in the patients chart, it was documented that he had
thick secretions and a productive cough. However, I assessed his cough to be dry and
non-productive. He is also currently receiving Lasix, Spironolactone, and Levofloxacin
to help decrease the congestion in his lungs. Davis Drug Guide Online
11. Furosemide (Lasix) is a loop diuretic that inhibits the reabsorption of sodium and chloride
from the loop of Henle and distal renal tubule. It increases secretion of water, sodium, chloride,
magnesium, potassium, and calcium. Loop diuretics cause greater diuretics than thiazide or
potassium sparing diuretics. Patient was admitted with pulmonary edema and has been
diagnosed with pneumonia; therefore it is important to use diuretics to help reduce the amount
of congestion in his lungs secondary to pulmonary edema which is causing impaired gas
exchange. It is important to monitor his lung sounds to determine if this intervention is in fact
helping the problem. Patient also has a history of HTN and by administering the Lasix this will
help lower his BP and reduce the workload of his heart.
Davis drug guide online
12. Spironolactone (Aldactone) is a potassium-sparing diuretic. It causes loss of
sodium bicarbonate and calcium while saving potassium and hydrogen ions by
antagonizing aldosterone. Patient was admitted with pulmonary edema, pneumonia and
had a BNP level of 863. It is important to remove the excess fluid so that his heart is
able to pump more effectively, as well as reduce the congestion in his lungs to ensure
adequate gas exchange. Patient also has a history of HTN, the combination of diuretics
and Metoprolol will help reduce the workload of his heart.
Davis Drug guide online
9. Outcome not met
Patients BNP level on
admission was 863 pg/mL
Since then he has received
Lasix, Spironolactone, and
Levofloxacin to help
remove the extra fluid and
infection in his lungs. BNP
drawn 2 days later was 93.
Plan is ongoing
10. Outcome not met
Patient did not produce any
sputum during my shift. In
addition to the medication, I
encouraged TCDB and use
of incentive spirometer
Plan is ongoing
11. Outcome not met
Patient had coarse crackles
in the bilateral bases of his
lungs. I did encourage TCDB
and IS and he is still
receiving levofloxacin
Plan is ongoing
12. Outcome not met
Patient had coarse
crackles in the BIL bases
of his lungs. I encouraged
TCDB and IS. He is also
still receiving Levofloxacin
Plan is ongoing
Melissa Wise Nursing 217
13. Patient will
have increased
tidal volume with
administration of
Ipratropium
Bromide Solution
qid
14. Patient will see
cardiologist for
follow up
appointment with
in one week of
discharge
13. Dependent
Administer
Ipratropium
Bromide solution
0.5 mg/2.5 ml
qid
15.Patient will
demonstrate
proper use of
incentive
spirometer to a
volume of 1200
mL q1h while
awake
Teach patient
proper use of
incentive
spirometer q1h
while awake
14. Collaborate
Assist patient to
set up consult
with cardiologist
after discharge
13 Ipratropium Bromide solution is a bronchodilator / anticholinergic drug that is delivered by
the inhalation and intranasal routes. It inhibits cholinergic receptors in bronchial smooth
muscle, resulting in decreased concentration of cGMP. Decreased levels of cGMP produces
local bronchodilation. Patient has been diagnosed with pulmonary edema and pneumonia. It
is important to administer a bronchodilator to ensure there is no airway constriction that will add
to his impaired gas exchange. Administration of a bronchodilator will also help increase
his tidal volume.
Davis Drug guide online
14. A cardiologist is a physician specializing in the treatment of heart disease. It is important for
the patient to follow up with a cardiologist to ensure that his heart is functioning at its full
capacity to prevent future hospitalizations. Currently the patient has an ineffective cardiac
pump which has caused pulmonary edema and impaired gas exchange. It is important for the
patient to be on the proper medication regimen and preventive measures to prevent any further
decline in his heart condition. On admission his BNP was 863 (normal is 0-100) This is
evidence that his heart was working much harder than it should be.
15. Respiratory muscle training improves muscle strength and endurance, resulting in
improved activity tolerance and helps prevent respiratory complications. One method for
respiratory muscle training is the use of an incentive spirometer (IS). The purpose of using the
IS is to expand alveoli, increase tidal volume, and prevent atelectasis & pneumonia. You take a
deep breath, exhale, then place lips tightly on the mouthpiece. Inhale deeply and slowly
through the mouth piece watching speed monitor & balls, bubbles or diaphragm depending on
the model being used. Then exhale. This should be done 5-10 time per hour while awake.
Patient was diagnosed with Pneumonia, therefore it is important for him to properly use the
incentive spirometer every hour to help expand the alveoli and to improve his gas exchange.
P&P p.854; class notes
13. Outcome not met
Patient’s lung sounds
continued to have coarse
crackles in the bil bases. I
encouraged TCDB and IS
Plan is ongoing
14. Outcome met
Patient has not been
discharged or seen
cardiologist at this point
Plan is ongoing
15. Outcome met
I did visualize the patient
properly using the incentive
spirometer multiple times
throughout my shift. He was
able to reach the level of
1200mL.
Plan is ongoing
Melissa Wise Nursing 217
Psychosocial Need
Prioritized Psychosocial Nursing Diagnosis: Risk for anxiety r/t changes in health status
Long-Term Goal: Patient will show no signs of anxiety
Outcome
Interventions
Rationale
Criteria
1. Patient will
identify/verbalize
anxiety as it happens
1. Assist patient in identifying
s/s of anxiety now
2. Patient will
verbalize 3 adaptive
coping mechanisms
after 1:1
2. Teach patient adaptive
coping mechanisms now
3. Patient will
demonstrate at least
one relaxation
technique after 1:1
3. Teach relaxation techniques
as needed
4. Patient will list 2
people for a support
system now
4. Help identify support system
for patient now
1. Anxiety often manifests as a vague, uneasy feeling or discomfort. It is quite
unpredictable and can sometimes become debilitating to the patient. Some physiological
characteristics of anxiety include dizziness, perspiration, frequent urination, palpitations,
dry mouth and restlessness. Behavioral characteristics include feeling of helplessness or
inadequacy, crying, difficulty concentrating and preoccupation. It is important for the
patient to be able to identify signs and symptoms of anxiety as they occur so that he can
use proper coping mechanisms or relaxation techniques. It appears that he has been fairly
healthy up until this point. His recent diagnosis of pulmonary edema and pneumonia could
cause increased anxiety because he will not be on more medications at home when he
leaves the hospital. He also had a pretty extensive nose bleed that could cause anxiety
thinking that it may occur again.
2. Coping is the person’s effort to manage psychological stress. Effectiveness of coping
strategies depends on the individual’s needs. A person’s age and cultural background
influence these needs, which is why no single coping strategy works for everyone or for
every stressor. Positive techniques include: seeking a social support system, adequate
nutrition, sleep, and exercise. Maladaptive coping mechanism we want the patient to
refrain from are alcohol or smoking, self-medicating, or disassociation with friends and
family. After this hospitalization there is a chance that he is going to go through some
lifestyle changes at home and it’s important for him to use adaptive coping mechanisms to
help him through this tough time
3. Some relaxation techniques are deep breathing, yoga, meditation, guided imagery,
progressive muscle relaxation and music/art therapy (among others). It is important to
identify relaxation techniques that would be beneficial to the specific patient seeing as
everyone finds different activities to be relaxing to them on a personal basis. Because his
body is going to be weak after this recent hospitalization, it is going to be important for him
to use relaxation techniques to help manage any anxiety he may encounter.
4. Having a strong support system after hospitalization can make a huge difference in the
patient’s recovery and can be critical to helping one get through the stress of tough times.
This patient will likely be discharged on more medications that he came in with and there is
a strong possibility he will have to make some follow up appointments to ensure that the
pneumonia and pulmonary edema have resolved as well as to have a check up to ensure
adequate heart function.
Evaluation
1. Outcome partially met
Multiple times through-out
the shift the patient seemed
to be preoccupied with the
thought of his nose bleeding
again and wondering what
caused it. He did not
however verbalize that he
was anxious about it
Plan is ongoing
2. Outcome not met
Patient did not verbalize 3
coping mechanisms. He
had company for the
majority of the night and was
pre occupied
Plan is ongoing
3. Outcome not met
Patient did not demonstrate
relaxation techniques. He
had company for the
majority of the night and was
pre occupied
Plan is ongoing
4.Outcome not met
Patient did not list 2 people
for a support system. He
did however have visitors for
the majority of the night.
Plan is ongoing