Impaired Gas_cervical Cancer

Need/Nursing Diagnosis/Cues Need: Physiologic need Nursing Diagnosis: Impaired gas exchange related to fluid overload as manifested by requirements of oxygen supplementation and shortness of breath with activity. Cues: Subjective cues: “Maglisud ko ug ginhawa maam”, as verbalized by the patient. Objective cues: • Rapid, shallow breathing •

Adventitious breath sounds noted (rhonchi, wheezes)

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Restlessness

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Dyspnea

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Use of accessory muscles for respiration

Scientific Analysis Due to fluid excess volume in the lung and exudates crosses the permeable membrane of the pleurae causing it to accumulate in this membranous space. Instead of the lungs being able to function normally, these fluids inhibit the lungs to expand anteroposteriorly thus causing ineffective breathing & discomfort.

Objective After 6-8 hours of nursing intervention, the patient will be able to: a. Patient will be able to breathe on room air without shortness of breath by discharge.

Nursing Intervention Independent: •

Rationale

Encouraged deep breathing techniques to open up lung bases increase oxygen exchange in blood. Taught patient the importance of deep breathing.

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Opening up all the way to the bases increases surface area for oxygen exchange.

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Auscultated breath sounds, listening for sounds of crackles or wheezes.

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It is important that patient be involved in their return to health and will increase compliance. The presence of crackles or wheezes would indicate fluid is filling her lungs: further exacerbation of fluid overload.

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Positioned in semifowler’s position.

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Sodium restricted diet.

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Monitored intake and output volumes.

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Weighted patient daily.

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Research indicates that keep the head of the bed elevated between a 30 – 45 degree angle increases oxygenation and gas exchange. (Ackley, B. J., Ladwig, G. B., 2008) Decreased amounts of sodium will reduce the amount of fluid retention which will help the underlying problem. To see a negative balance to confirm effectiveness of diuretics and other therapies to reduce fluids. This will show progress of fluid removal and help determine effectiveness of treatments.

Dependent: •

Administration of

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This will help remove some

Value Integration After 6-8 Sense of hours of responsibility nursing and intervention, accountability the patient in whatever was able to: actions being done. a. Patient was able to Selfbreathe on confidence in room air interacting without with the shortness of patient. breath by discharge. Evaluation