Impaired Gas Exchange

CUES Subjective Cues: No verbatim V2Incomprehensi ble sounds. Objective Cues: *restless *dyspnea *coarse crackles heard upin auscultation of  both lung fields (more prominent on right lung field) *RR=30 breaths/minut e with use of  accesory muscles *shallow inhalation and shallow expiration

Laboratory Results: ABG

DIAGNOSIS Impaired gas exchange related to pulmonary edema

RATIONALE Alcoholic cirrhosis leads to portal hypertension.  This would lead to inability of the circulating blood to pass through the liver. Since there is a buildup of circulating blood, there will inadequate ventricular function in the left side of the heart leading to left sided heart failure.

OUTCOME

1. The patient will be able to demonstrate adequate ventilation and oxygenation as evidenced by patient’s ABG in normal range after 72 hours of  nursing care. 2. The patient will display resolution or absence of  symptoms of  respiratory distress as evidenced by RR=12-20 breaths/minute, An inadequate which is normal in left ventricular rate and rhythm function in Heart and capillary refill Failure, causes time of less than an increased 2 seconds after microvascular 72 hours of  pressure from nursing care. abnormal cardiac function causing the blood to back up into the pulmonary vasculature and

INTERVENTIONS

RATIONALE

1. Assess vital signs Note cardiac rhythm, respiratory rate and depth and work of breathing (such as use of  accessory muscles or nasal flaring and pursed-lip breathing) Report vital sign changes.

1. Tachypnea and dyspnea accompany pulmonary obstruction. Dyspnea and increased work of  breathing may be first or only sign of  subacute PE. Severe respiratory distress and failure accompanies moderate to severe loss of functional lung units.

INDICATORS

1-3 a. identifies the health needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of  equipments g. fulfills legal requirements in nursing practice h. accomplishes 2. Assess level of  accurate documentation consciousness and 2. Systemic in all matters evaluate hypoxemia may be concerning patient care mentation demonstrated in accordance to the changes. initially by standards of nursing restlessness and practice irritability, then by i. detects variation in progressively the vital signs of the decreased patient from day to day mentation  j. shares with team 3. Assess activity current information tolerance, such as regarding particular reports of  patient condition weakness and 3. Nonventilated k.performs daily check fatigue, vital sign areas may be patient’s condition changes, or identified by l. completes updated

Respiratory Acidosis pH= 7.29 HCO3= 20 PaCO2= 55 PaO2 = 88

Chest X-ray Densities produced by fluid,

as fluid begins to leak into the interstitial space and the alveoli it leads to a deficit in oxygenation and carbon dioxide elimination at the alveolicapillary membrane.

increased dyspnea during exertion. Auscultate lungs for areas of  decreased and absent breath sounds and the presence of  adventitious sounds, such as crackles. 4. Institute measures to restore or maintain patent airways, suctioning.

absence of breath sounds. Crackles occur in fluid filled tissues and airways or may reflect cardiac decompensation.

documentation of  patient care

a. identifies the health needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of  equipments

4. Plugged or collapsed airways reduce number of  functional alveoli, negatively affecting a. identifies the health gas exchange. needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques 5. Elevate head of  f. checks proper bed as client Promotes maximal functioning of  tolerates. chest expansion, equipments making it easier to breathe and a. identifies the health enhancing needs of the patient physiological and b. identifies the problem psychological c, gathers data related

comfort.

6. Assist with frequent changes of position.

 Turning enhances aeration of different lung segments, thereby improving oxygen diffusion.

to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of  equipments

7-13 a) Identifies the health needs of the Collaborative patients 7. Prepare for lung gathers data b) scan. May reveal pattern related to problem 8. Monitor serial of abnormal analyz es the da ta ABGs or pulse perfusion in areas of  c) gathered oximetry. ventilation, d) perform agereflecting specific safety and ventilation and perfusion mismatch, comfort measures in all aspect of patient care confirming performs diagnosis of PE and e) appropriate assessment degree of  techniques obstruction. f) implements Absence of both nursing intervention ventilation and that is safe and perfusion reflects comfortable 9. Administer alveolar

supplemental oxygen by appropriate method.

11.Provide supplemental humidification, such as ultrasonic nebulizers.

12.Assist with chest physiotherapy, such as postural drainage and percussion of  nonaffected area, blow bottles, and

congestionn or airway obstruction.

g) checks proper functioning of  equipments Hypoxemia is h) demonstrate present in varying knowledge of method degrees, depending appropriate for the on the amount of  clinical problem airway obstruction, identified usual participates i) cardiopulmonary actively in the care function, and management including presence and audit degree of shock. j) respect roles of   Respiratory alkalosis other members of  and metabolic health team acidosis may also k) refer patients to be present. allied health team partners Maximizes available act as liaison for oxygen for gas patients exchange, reducing work of breathing. Note: If obstruction is large or hypoxemia does not respond to supplemental oxygenation, it may be necessary to move client to critical care area for intubation and mechanical ventilation.

incentive spirometer. Facilitates deeper respiratory effort and promotes drainage of  secretions from lung 13.Prepare for and segments into assist with bronchi, where they bronchoscopy. may more readily be removed by coughing or suctioning. 14. Administer medications as ordered. Diuretics (Thiazide May be done to diuretics) remove blood clots and clear airways.

Digitalis preparation

*identifies the health needs of the patients *gathers data related to problem analyzes the data gathered *perform age-specific safety and comfort measures in all aspect of patient care *conforms to the 10 golden rules in administration and health therapeutics *performs appropriate - medications used assessment techniques to increase the rate *implements nursing of  intervention that is safe urine production and comfortable and the removal of  *participates actively in excess extracellular the care management fluid from including audit the body. *respect roles of other members of health - The medication team increases the force refer patients to allied of myocardial health team partners

contraction and *act as liaison for slows conduction patients through the AV node. It improves contractility, increasing left ventricular output.  The medication also enhances diuresis, which removes fluid and relieves edema.