Question

Martha Moore is an 87-year-old woman with a history of osteoporosis and hypertension. She had an exploratory laparotomy for a small-bowel obstruction 2 days ago. Before assessing this patient you notice her hemoglobin level is 9 mg and her SaO₂ is 90%. You do her morning assessment and she reports her cough kept her awake last night. Currently her temperature is 101⁰ F, her BP is 150/78, her heart rate is 100, and her respiratory rate is 24 breaths/min. On auscultation you hear crackles in both lungs. The patient reports a sharp pain in her chest when she takes a deep breath. After the deep breath, she has a productive cough and you notice the sputum is green with rust-colored tinting. Mrs. Moore reports she tries not to cough because it causes abdominal pain at her incision site.

1. What risk factors do you identify for impaired gas exchange from Mrs. Moore?

2. What conclusions (nursing diagnoses) can you make after your assessment?

3. What is your care plan for Mrs. Moore?

4. How would you evaluate effectiveness of your plan?

Answer 1

1.Atlectasis,pneumonia,pulmonary edema ,acute respiratory distress syndrome,decreased oxygen saturation and low haemoglobin level are the main risk factors for impaired gas exchange.

2.Nursing diagnosis

*Impaired gas excahnge and airway clearance related to abdomial surgery.

*Ineffective airway clearance related to bronchoconstriction /broncho-pulmonary infections.

*Ineffective breathing pattern  related to shortness of breath / productive cough /prolonged immobility.

*Activity intolerance related to fatigue /hypoxaemia /anaemia.

*Acute pain related to Expoloratory laprotomy.

3.careplans

*Instruct and encourage tha patient about the diaphragmatic breathing and effective coughing exercise.

*Administer oxygen and analyse the Arterial blood gas level if the saturation is below 90%.

*Initiate the effectiveness of nebulizer to reduce the crackles of the lungs.

*Hydrate the patient adequately.

*Administer antibiotics ,bronchodialators as prescribed by the physician.

*Provide physiotherapy if needed.

*Educate the patient to practice incentive spirometry.

*Provide comfortable position to promote rest and breathing.

*Monitor the respiratory rate frequently.

*Provide Blood transfusion if needed.

*Advise the patient to sup[port the surgical site with a soft cloth or blanket while coughing or sneezing.

*Monitor the vital signs frequently.

*Educate the client about the importance of early ambulation and high protein and iron rich diet.

4.Evaluation of careplans are:Deep breathing and coughing exercise helpds to expel out the sputum completely.Bronchodilators helps to loos the mucus and antibiotics helps to reduce the infection rate nad promote healing fast.By assesing ABG level helps the oxygen saturation.Hydrating the patient frequently helps to reduce fatigue and weakness and also helps to reduce pain.early ambulation helps to reduce pain .High protein diet helps early healing.Supporting a pillow or blanket over the surgical site will helps to reduce extra strain over the site.