CARDIAC COMPLICATION ASSESSMENT SUBJECTIVE: I find myself having shortness of breath that wakes me up at night as stated by the patient.

verbalization of DOB, shortness of breath that wakes the client at night and complaint of extreme fatigue, chest pain and skip breaths OBJECTIVES: -24 weeks pregnant -Use of 2 pillows when she sleeps -cough -pallor -capillary refill more than 3 seconds -palmar cyanosis -buccal cyanosis -Palpebral cyanosis -crackles on both lung fields -RR 26cpm -PR 110 bpm -ECG revealed arrythmia NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING Client will exhibit signs of effective breathing pattern. INTERVENTION - Assess skin color, temperature, capillary refill; note central versus peripheral cyanosis. - Position patient with proper body alignment. (left side lying position) - if client must remain flat in bed, assist with position change at least every 2 hours unless contraindicated - instruct client to deep breathe or use incentive spirometer every 1 - 2 hours - perform actions to reduce chest or abdominal pain if present (e.g. splint chest/abdomen with a pillow when positioning, coughing, and deep breathing; administer prescribed analgesics) - perform actions to decrease fear and - instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals RATIONALE EVALUATION

Ineffective breathing pattern related to compression of the inferior vena cava as evidenced by RR 26

- for optimal breathing pattern. - to prevent slumping

-in order to increase the client's willingness to move and breathe more deeply

- in order to prevent the shallow and/or rapid breathing that can occur with fear and anxiety - in order to prevent gastric distention and additional pressure on the diaphragm

PLACENTA PREVIA ASSESSMENT SUBJECTIVE: NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTION - Explain that the fetus survival depends on gestational age and amount of maternal blood loss. -Advise the patient to frequent monitoring and prompt management neonatal -Encourage the patient and her family to verbalize their feelings RATIONALE EVALUATION

Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation

- greatly reduce the risk of neonatal death. -helps them to develop effective coping strategies, and refer them for counseling, if necessary. - discharge to detect early signs of infection resulting from exposure of placental tissue.

OBJECTIVES:

-Monitor VS for elevated temperature, pulse, and blood pressure, monitor laboratory results for elevated WBC count, differential shift; check for urine tenderness and malodorous vaginal -Provide or teach perineal hygiene -Observe for abnormal fetal heart rate patterns such as loss of variability, decelerations tachycardia -Position the patient in side lying position and wedge -Assess fetal -Teach woman to monitor fetal movement -Administer oxygen as

- to decrease the risk of ascending infection. - to identify fetal distress.

- for support to maximize placental perfusion. - movement to evaluate for possible fetal hypoxia. - to evaluate well being

ABRAPTIO PLACENTA ASSESSMENT SUBJECTIVE: NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTION - monitor amount of bleeding by weighing all pads -investigate all pain reports, noting location, duration, intensity and characteristics -monitor maternal vital signs and fetal heart rate through continuous monitoring - measure and record fundic height - position mother in left lateral position with the head of the bed elevated -provide comfort measures like back rubs, deep breathing RATIONALE -to measure the amount of blood loss -change in location or intrnsity are not uncommon but may reflect developing complications -early recognition of possible adverse effect allows prompt intervention -fundal height may increase with concealed bleeding -to enhance placental perfusion -promotes relaxation and may enhance patients coping abilities by refocusing After 8 hours of nursing intervention the patient was able to demonstrate the use of relaxation technique and other methods to promote comfort EVALUATION

Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation

OBJECTIVES:

After 8 hours of nursing intervention the patient will demonstrate the use of relaxation technique and other methods to promote comfort

ECTOPIC PREGNANCY ASSESSMENT SUBJECTIVE: NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTION - Assess respirations: note quality, rate, pattern, depth, and breathing effort - assess level of RATIONALE - reduce lung volume and decrease ventilation. EVALUATION

Impaired Gas exchange Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

OBJECTIVES:

Patient maintains optimal gas exchange as evidenced by normal arterial blood gases (ABGs) and alert responsive mentation or no further reduction in mental status.

After 8 hours of nursing intervention the patient was able to demonstrate the use of relaxation technique and other methods to promote comfort

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Nursing Care of the Pediatric Neurosurgery Patient

7.14.2009
NCP Nursing Diagnosis: Impaired Gas Exchange

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0digg Nursing Diagnosis: Impaired Gas Exchange Ventilation or Perfusion Imbalance NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels * Respiratory Status * Gas Exchange NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels * Respiratory Monitoring * Oxygen Therapy * Airway Management NANDA Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane By the process of diffusion the exchange of oxygen and carbon dioxide occurs in the alveolar-capillary membrane area. The relationship between ventilation (airflow) and perfusion (blood flow) affects the efficiency of the gas exchange. Normally there is a balance between ventilation and perfusion; however, certain conditions can offset this balance, resulting in impaired gas exchange. Altered blood flow from a pulmonary embolus, or decreased cardiac output or shock can cause ventilation without perfusion. Conditions that cause changes or collapse of the alveoli (e.g., atelectasis, pneumonia, pulmonary edema, and adult respiratory distress syndrome [ARDS]) impair ventilation. Other factors affecting gas exchange include high altitudes, hypoventilation, and altered oxygen-carrying capacity of the blood from reduced hemoglobin. Elderly patients have a decrease in pulmonary blood flow and diffusion as well as reduced ventilation in the dependent regions of the lung where perfusion is greatest. Chronic

conditions such as chronic obstructive pulmonary disease (COPD) put these patients at greater risk for hypoxia. Other patients at risk for impaired gas exchange include those with a history of smoking or pulmonary problems, obesity, prolonged periods of immobility, and chest or upper abdominal incisions. * * * * * * * * * * * Defining Characteristics: Confusion Somnolence Restlessness Irritability Inability to move secretions Hypercapnia Hypoxia Related Factors: Altered oxygen supply Alveolar-capillary membrane changes Altered blood flow Altered oxygen-carrying capacity of blood

* Expected Outcomes Patient maintains optimal gas exchange as evidenced by normal arterial blood gases (ABGs) and alert responsive mentation or no further reduction in mental status. Ongoing Assessment * Assess respirations: note quality, rate, pattern, depth, and breathing effort. Both rapid, shallow breathing patterns and hypoventilation affect gas exchange. Shallow, "sighless" breathing patterns postsurgery (as a result of effect of anesthesia, pain, and immobility) reduce lung volume and decrease ventilation. * Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds. * Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis, headache, lethargy, and confusion. * Assess for signs and symptoms of atelectasis: diminished chest excursion, limited diaphragm excursion, bronchial or tubular breath sounds, rales, tracheal shift to affected side. Collapse of alveoli increases physiological shunting. * Assess for signs or symptoms of pulmonary infarction: cough, hemoptysis, pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural friction rub, fever. * Monitor vital signs. With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise. As the hypoxia and/or hypercapnia becomes more severe, BP may drop, heart rate tends to continue to be rapid with arrhythmias, and respiratory failure may ensue with the patient unable to maintain the rapid respiratory rate. * Assess for changes in orientation and behavior. Restlessness is an early sign of hypoxia. Chronic hypoxemia may result in cognitive changes such as memory changes.

* Monitor ABGs and note changes. Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate will decrease and PaCO2 will begin to rise. Some patients, such as those with COPD, have a significant decrease in pulmonary reserves, and any physiological stress may result in acute respiratory failure. * Use pulse oximetry to monitor oxygen saturation and pulse rate. Pulse oximetry is a useful tool to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater. This tool can be especially helpful in the outpatient or rehabilitation setting where patients at risk for desaturation from chronic pulmonary diseases can monitor the effects of exercise or activity on their oxygen saturation levels. Home oxygen therapy can then be prescribed as indicated. Patients should be assessed for the need for oxygen both at rest and with activity. A higher liter flow of oxygen is generally required for activity versus rest (e.g., 2 L at rest, and 4 L with activity). Medicare guidelines for reimbursement for home oxygen require a PaCO2 less than 58 and/or oxygen saturation of 88% or less on room air. Oxygen delivery is then titrated to maintain an oxygen saturation of 90% or greater. * Assess skin color for development of cyanosis. For cyanosis to be present, 5 g of hemoglobin must desaturate. * Monitor chest x-ray reports. Chest x-rays may guide the etiological factors of the impaired gas exchange. Keep in mind that radiographic studies of lung water lag behind clinical presentation by 24 hours. * Monitor effects of position changes on oxygenation (SaO2, ABGs, SVO2, and end-tidal CO2). Putting the most congested lung areas in the dependent position (where perfusion is greatest) potentiates ventilation and perfusion imbalances. * Assess patients ability to cough effectively to clear secretions. Note quantity, color, and consistency of sputum. Retained secretions impair gas exchange. Therapeutic Interventions * Maintain oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater. This provides for adequate oxygenation. Avoid high concentration of oxygen in patients with COPD. Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patients PaO2, which could result in apnea. NOTE: If the patient is allowed to eat, oxygen still must be given to the patient but in a different manner (e.g., changing from mask to a nasal cannula). Eating is an activity and more oxygen will be consumed than when the patient is at rest. Immediately after the meal, the original oxygen delivery system should be returned. * For patients who should be ambulatory, provide extension tubing or portable oxygen apparatus. These promote activity and facilitate more effective ventilation. * Position with proper body alignment for optimal respiratory excursion (if tolerated, head of bed at 45 degrees). This promotes lung expansion and improves air exchange. * Routinely check the patients position so that he or she does not slide down in bed. This would cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment. * Position patient to facilitate ventilation/perfusion matching. Use upright, high-Fowlers position whenever possible. High-Fowlers position allows for

optimal diaphragm excursion. When patient is positioned on side, the good side should be down (e.g., lung with pulmonary embolus or atelectasis should be up). * Pace activities and schedule rest periods to prevent fatigue. Even simple activities such as bathing during bed rest can cause fatigue and increase oxygen consumption. * Change patients position every 2 hours. This facilitates secretion movement and drainage. * Suction as needed. Suction clears secretions if the patient is unable to effectively clear the airway. * Encourage deep breathing, using incentive spirometer as indicated. This reduces alveolar collapse. * For postoperative patients, assist with splinting the chest. Splinting optimizes deep breathing and coughing efforts. * Encourage or assist with ambulation as indicated. This promotes lung expansion, facilitates secretion clearance, and stimulates deep breathing. * Provide reassurance and allay anxiety: o Have an agreed-on method for the patient to call for assistance (e.g., call light, bell). o Stay with the patient during episodes of respiratory distress. * Anticipate need for intubation and mechanical ventilation if patient is unable to maintain adequate gas exchange. Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient. Mechanical ventilation provides supportive care to maintain adequate oxygenation and ventilation to the patient. Treatment also needs to focus on the underlying causal factor leading to respiratory failure. * Administer medications as prescribed. The type depends on the etiological factors of the problem (e.g., antibiotics for pneumonia, bronchodilators for COPD, anticoagulants/thrombolytics for pulmonary embolus, analgesics for thoracic pain). Education/Continuity of Care * Explain the need to restrict and pace activities to decrease oxygen consumption during the acute episode. * Explain the type of oxygen therapy being used and why its maintenance is important. Issues related to home oxygen use, storage, or precautions need to be addressed. * Teach the patient appropriate deep breathing and coughing techniques. These facilitate adequate air exchange and secretion clearance. * Assist patient in obtaining home nebulizer, as appropriate, and instruct in its use in collaboration with respiratory therapist. * Refer to home health services for nursing care or oxygen management as appropriate.

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