CARE PLANCARE PLANOXYGENATIONOXYGENATION

ASSESSMENTASSESSMENTMr. King’s physician diagnosed him with Mr. King’s physician diagnosed him with

an upper respiratory infection. He is an upper respiratory infection. He is restlessrestless and and anxiousanxious and has continuing and has continuing dyspneadyspnea, and , and a productive a productive coughcough, with dark yellow , with dark yellow sputumsputum. . On auscultation there are On auscultation there are audible expiratory audible expiratory wheezeswheezes, , cracklescrackles,, and and diminished breathdiminished breath sounds over right lower lobesounds over right lower lobe. His vital signs . His vital signs are pulse rate 120, temp 102 deg F, are pulse rate 120, temp 102 deg F, increased increased respiratory rate 36respiratory rate 36, BP 110/45 and an , BP 110/45 and an SpO2 SpO2 of 82%.of 82%. As the day progresses Mary notices As the day progresses Mary notices that his coughs are weaker, less sputum is that his coughs are weaker, less sputum is produced, and Mr. King is becoming more produced, and Mr. King is becoming more fatigued.fatigued.

NNURSING DIAGNOSIS

Ineffective airway clearance Ineffective airway clearance related to increased related to increased

secretionssecretions

PLANNINGPLANNING

GOALGOAL Pulmonary Pulmonary

secretions will secretions will return to return to baseline levels baseline levels within 24 to 36 within 24 to 36 hours.hours.

EXPECTED OUTCOMESEXPECTED OUTCOMES Patient’s sputum will be clear, Patient’s sputum will be clear,

white and thinner consistency white and thinner consistency within 36hours.within 36hours.

Patient’s lung sounds will be Patient’s lung sounds will be at baseline within 36 hours.at baseline within 36 hours.

Patient’s respiratory rate will Patient’s respiratory rate will be between 16 and 24 within be between 16 and 24 within 24 hours.24 hours.

Patient will be able to clear Patient will be able to clear airway secretions by coughing airway secretions by coughing in 24 hours.in 24 hours.

Patient’s SpO2 will be >85% Patient’s SpO2 will be >85% within 24 hours.within 24 hours.

Patient’s perceptions of Patient’s perceptions of dyspnea will improve.dyspnea will improve.

INTERVENTIONSAIRWAY MANAGEMENTAIRWAY MANAGEMENT Have Mr. King deep Have Mr. King deep breathe and cough breathe and cough every 2 hours while every 2 hours while awake.awake.

Have Mr. King Have Mr. King change position change position frequently if in bed frequently if in bed rest. If able, have him rest. If able, have him to sit up in a chair as to sit up in a chair as often as he is able to often as he is able to tolerate.tolerate.

RATIONALERATIONALE A major complication of A major complication of reduced mobility is reduced mobility is retention of pulmonary retention of pulmonary secretions, which secretions, which predisposes the patient to predisposes the patient to atelectasis & pneumonia.atelectasis & pneumonia.

Ambulation, sitting Ambulation, sitting upright and frequent upright and frequent position changes are position changes are consistent with normal consistent with normal activities and promote activities and promote normal lung function and normal lung function and mucociliary clearance.mucociliary clearance.

Encourage Mr. king Encourage Mr. king to increase fluid to increase fluid intake to 2800ml/24intake to 2800ml/24hours if his cardiac hours if his cardiac condition does not condition does not contraindicate it. contraindicate it. Avoid caffeinated Avoid caffeinated beverages and beverages and alcohol; recommend alcohol; recommend water.water.

Fluid intake of Fluid intake of 2800ml/24 hrs will 2800ml/24 hrs will help liquefy help liquefy secretions for easier secretions for easier removal. Caffeinated removal. Caffeinated and alcoholic and alcoholic beverages promote beverages promote diuresis and diuresis and dehydration. Water dehydration. Water is an effective is an effective expectorant, easily expectorant, easily available & cost available & cost effective.effective.

EVALUATIONEVALUATION Ask Mr. King about the color of his Ask Mr. King about the color of his

sputum.sputum. Auscultate lungs for adventitious lung Auscultate lungs for adventitious lung

sounds.sounds. Ask Mr. King to rate his perception of Ask Mr. King to rate his perception of

dyspnea, using a visual analog scale.dyspnea, using a visual analog scale. Ask Mr. King if he is able to cough and Ask Mr. King if he is able to cough and

expectorate his secretions.expectorate his secretions. Obtain vital signs and SpO2 measures.Obtain vital signs and SpO2 measures.

CaseCase

Juan Paolo admitted to ER for Juan Paolo admitted to ER for morphine drug overdose. He is morphine drug overdose. He is lethargic and stuporous; T98.9, P120, lethargic and stuporous; T98.9, P120, R13 and very shallow. ABG results: R13 and very shallow. ABG results: pH 7.28, PaCO2 49mm Hg and HCO3 pH 7.28, PaCO2 49mm Hg and HCO3 25 mEq/l.25 mEq/l.

Identify priority nursing diagnosis Identify priority nursing diagnosis and interventions.and interventions.

ABG InterpretationABG Interpretation

Look at pH, normal 7.35-7.45Look at pH, normal 7.35-7.45 Look at PaCO2. more than 45 mm Look at PaCO2. more than 45 mm

Hg, less CO2 is being exhaled than Hg, less CO2 is being exhaled than normal.normal.

Look at HCO3, normal 22-26; with Look at HCO3, normal 22-26; with acidosis and retained CO2 is causing acidosis and retained CO2 is causing respiratory acidosis. Uncompensated.respiratory acidosis. Uncompensated.

PHYSICAL SIGNS OF NUTRITIONAL STATUSPHYSICAL SIGNS OF NUTRITIONAL STATUS

Body AreaBody Area General appearanceGeneral appearance WeightWeight

PosturePosture

MusclesMuscles

Nervous controlNervous control

Normal AppearanceNormal Appearance Alert responsiveAlert responsive Normal for height, age, Normal for height, age, body buildbody build Erect, arms and legs Erect, arms and legs straightstraight Well-developed, firm, Well-developed, firm,

good tone, some fat good tone, some fat under skinunder skin

Good attention span, not Good attention span, not irritable or restless, normal irritable or restless, normal reflexes, psychological reflexes, psychological stability stability

Gastrointestinal Gastrointestinal

functionfunction

Cardiovascular Cardiovascular

functionfunction

General VitalityGeneral Vitality

Good appetite & digestion, Good appetite & digestion,

normal regular elimination, normal regular elimination,

no palpable (perceptible to no palpable (perceptible to

touch) organs or massestouch) organs or masses

Normal heart rate & Normal heart rate &

rhythm, no murmuring, rhythm, no murmuring,

normal BP for agenormal BP for age

Endurance, energetic, Endurance, energetic,

sleeps well, vigoroussleeps well, vigorous

HairHair

Skin (general)Skin (general)

Face and neckFace and neck

LipsLips

Shiny, lustrous, firm, not Shiny, lustrous, firm, not

easily plucked, healthy scalpeasily plucked, healthy scalp

Smooth, slightly moist, Smooth, slightly moist,

good colorgood color

Skin color uniform, Skin color uniform,

smooth, healthy appearance, smooth, healthy appearance,

not swollennot swollen

Smooth, good color, moist, Smooth, good color, moist,

not chapped or swollennot chapped or swollen

Mouth, oral Mouth, oral mucous mucous membranesmembranes

GumsGums

TongueTongue

Reddish pink mucous Reddish pink mucous membranes in oral membranes in oral cavitycavity

Good pink color, Good pink color, healthy, red no swelling healthy, red no swelling or bleedingor bleeding

Good pink color or Good pink color or deep reddish in deep reddish in appearance, not appearance, not swollen or smooth, swollen or smooth, surface papillae present, no surface papillae present, no lesionslesions

TeethTeeth EyesEyes

Neck (glands)Neck (glands) NailsNails Legs and feetLegs and feet

SkeletonSkeleton

No pain, no sensitivityNo pain, no sensitivity Bright, clear, shiny, no sores Bright, clear, shiny, no sores

at corner of eyelids, at corner of eyelids, membranes moist and membranes moist and healthy pink color, no healthy pink color, no prominent blood vessels or prominent blood vessels or mound of tissue or sclera, mound of tissue or sclera, no fatigue circles beneathno fatigue circles beneath

No enlargementNo enlargement Firm, pinkFirm, pink No tenderness, weakness or No tenderness, weakness or

swelling; good colorswelling; good color No malformationsNo malformations

CLINICAL CLINICAL FACTORS/CONDITIONS THAT FACTORS/CONDITIONS THAT

RESPOND TO OR BE RESPOND TO OR BE AFFECTED BY IV FLUID AFFECTED BY IV FLUID

ADMINISTRATIONADMINISTRATION

a.a. Peripheral edema – Peripheral edema – can can

be rated for severity by be rated for severity by assessing pitting over assessing pitting over bony prominences. 1+ bony prominences. 1+ indicates barely indicates barely

detectable detectable edema to 4+ for deep edema to 4+ for deep persistent pittingpersistent pitting

b. Body weightb. Body weight

a. Indicates expanded a. Indicates expanded interstitial volume. This interstitial volume. This is usually most evident is usually most evident in dependent areas (i.e., in dependent areas (i.e., feet and ankles). Fluid feet and ankles). Fluid overload will worsen overload will worsen Edema.Edema.

b. Daily weights b. Daily weights document fluid retention document fluid retention or loss. Change in body or loss. Change in body weight of 1kg weight of 1kg corresponds to 1L of corresponds to 1L of fluid retention loss. fluid retention loss.

c. Dry skin and c. Dry skin and mucous mucous membranesmembranes

d. Distended d. Distended neck veinsneck veins

e. Blood e. Blood pressure pressure changeschanges

c. Suggests fluid volume c. Suggests fluid volume deficit.deficit.

d. Suggests fluid volume d. Suggests fluid volume excess.excess.

e. Elevated BP indicates e. Elevated BP indicates volume excess due to volume excess due to increase in stroke volume. increase in stroke volume. Decreased BP indicates Decreased BP indicates fluid volume deficit due to fluid volume deficit due to a decrease in stroke a decrease in stroke volumevolume

f. Irregular pulse f. Irregular pulse

rhythm; rhythm;

increased pulse increased pulse

raterate

g. Auscultation g. Auscultation

crackles or crackles or

rhonchi in lungsrhonchi in lungs

f. Rhythm changes f. Rhythm changes

occur with potassium, occur with potassium,

calcium, and/or calcium, and/or

magnesium magnesium

abnormalities; rate abnormalities; rate

change occurs with fluid change occurs with fluid

volume deficitvolume deficit

g. May signal fluid build g. May signal fluid build

up in the lungs due to up in the lungs due to

fluid volume excessfluid volume excess

h. h. Inelastic skin Inelastic skin

turgor (after turgor (after

pinching, fails to pinching, fails to

return to normal return to normal

position within 3 position within 3

secondsseconds

i. Anorexia, nausea i. Anorexia, nausea

and vomitingand vomiting

j. Thirstj. Thirst

h. With fluid volume h. With fluid volume

deficit, the pinched deficit, the pinched

skin stays elevated skin stays elevated

for several seconds.for several seconds.

i. May occur with i. May occur with

acute fluid volume acute fluid volume

deficit or fluid deficit or fluid

volume excess.volume excess.

j. Symptomatic of j. Symptomatic of

fluid volume deficitfluid volume deficit

k. Decreased k. Decreased urine outputurine output

l. Behavioral l. Behavioral changes (e.g., changes (e.g., restlessness, restlessness, confusion)confusion)

m. Decreased m. Decreased capillary refillcapillary refill

k. During dehydration, kidney k. During dehydration, kidney attempts to restore fluid balance attempts to restore fluid balance by reducing urine production. by reducing urine production. Average daily adult urine output Average daily adult urine output is 1500ml; urine output of less is 1500ml; urine output of less than 400ml/24 hr (oliguria) than 400ml/24 hr (oliguria) signals the retention metabolic signals the retention metabolic Wastes.Wastes.

l. May occur with fluid volume l. May occur with fluid volume deficit or acid-base imbalancedeficit or acid-base imbalance

m. May suggest poor tissue m. May suggest poor tissue perfusion due to fluid deficitperfusion due to fluid deficit