Question

Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition.

Write a Nursing plan. Write a Nursing Care Plan Assessment, Diagnosis, Goal, Implement, Evaluation

Answer 1

NURSING CARE PLAN

ASSESSMENT

Assess respiratory rate, depth, abnormal breathing patterns.

Monitor patient’s behaviour and mental status for onset of restlessness, agitation, confusions

Observe for nail beds, cyanosis in skin.

Monitor oxygen saturation continuously, using pulse oximeter.

Note blood gas (ABG) results as available and note changes.

NURSING DIAGNOSIS

Impaired gas exchanged related to airway obstruction as evidence by restless, shortness of breath and confusion.

GOALS

To improve gas exchange and improve breathing pattern.

INTERVENTIONS

1. Position patient with head of bed elevated, in a semi-Fowler’s position (head of bed at 45 degrees when supine) as tolerated.

RATIONAL: Upright position or semi-Fowler’s position allows increased thoracic capacity, full descent of diaphragm, and increased lung expansion preventing the abdominal contents from crowding.

2. Suction as necessary.

RATIONAL: Suction clears secretions if the patient is not capable of effectively clearing the airway. Airway obstruction blocks ventilation that impairs gas exchange.

3. Maintain an oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater

RATIONAL: Supplemental oxygen may be required to maintain PaO2 at an acceptable level.

4. Provide reassurance and reduce anxiety.

RATIONAL: Anxiety increases dyspnea, respiratory rate, and work of breathing.

EVALUATION

Patient will be able to breathe normally and reduced restlessness and relieved from confusions