Nursing Care Plan 4 Gas Exchange, Impaired

Case Scenario #5 Pediatric ICU INSTRUCTIONS: For this case scenario, you will develop a Nursing Care Plan using SNL, the Standardized Nursing Languages of NANDA, NOC and NIC (NNN). You will be completing the blank nursing care plan that accompanies this scenario. Patient is a 4-month-old boy who has been admitted to the PICU after being seen in the ED with severe respiratory distress and dehydration. Temperature = 39°, pulse = 200, RR = 68 and shallow. He has poor response to NMT treatments x 2. An ABG = O2 sat of 80, pH of 7.3, PO2 of 75, and CO2 of 50. An IV is started and he is intubated. His medical diagnosis is RSV pneumonitis, possible bacterial pneumonia, and respiratory failure.

Functional Health Patterns Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct the choice of Nursing Diagnoses. The eleven functional health patterns are Health Perception-Health Management; Cognitive-Perceptual; Nutritional-Metabolic; Elimination; ActivityExercise; Sleep/Rest; Self-Perception/Self-Concept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief.

Ø Health Perception/Management: Previously healthy infant with 2 day history of fever, cough, dyspnea & vomiting. Mother and both siblings have had colds. On no medication at home. Immunizations are up to date. Ø Role/Relationship: Patient is accompanied by his mother. Patient lives with mother, age 18, 2 siblings ages 2 and 3, and maternal grandmother. Patient’s father is not involved in his care. Patient’s mother appears concerned and states she did not realize that her baby was so sick. Ø Activity/Exercise: Breath sounds are very coarse and congested. He has many secretions. He is restless and agitated. Ø Elimination: No urine output for the last 8 hours. No bowel movement for 2 days. Activity-Exercise I is the most affected functional health pattern for this patient.

NURSING DIAGNOSIS

Appropriate nursing diagnoses (NANDA) for this patient would include: Gas exchange, impaired Defining Characteristics: Decreased PO2 Abnormal arterial pH Irritability/restlessness Abnormal rate, rhythm, depth of breathing Related factors (Etiology): RSV pneumonitis Possible bacterial pneumonia

Fluid volume deficit Defining Characteristics: Decreased urine output Increased body temperature Decreased skin turgor Increased pulse rate Related Factors (Etiology): Decreased fluid intake

Hyperthermia Defining Characteristics: Increase in body temperature above normal range Warm to touch Increased respiratory rate Related Factors (Etiology): Atypical pneumonia Dehydration

While all these nursing diagnoses are appropriate, for purposes of this exercise let’s use:

Gas Exchange, Impaired.

On the nursing care plan form write in the nursing diagnosis and check the defining characteristics and related factors (Etiology).

Lynda/NNN/Case Study/Ped ICU 12/14/01

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Nursing Outcomes (NOCs) •

The next step is to select nursing outcomes that can best affect this nursing diagnosis.

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Listed below are two appropriate nursing outcomes for this patient.

Respiratory Status: Gas Exchange Indicators: Ease of breathing

Dyspnea at rest not present Cyanosis not present Neurological Status IER Restlessness not present Fatigue not present Pao2 WNL Paco2 WNL O2 saturation WNL

Respiratory Status: Ventilation Indicators: Respiratory rate IER*

Respiratory rhythm IER Ease of breathing Dyspnea at rest not present

*IER = In expected range Select ONE of the above listed nursing outcomes for this care plan exercise, go to the nursing care plan and check the indicators that you think will best measure your patient’s progress towards the outcome that you’ve chosen. You will need to RATE you patient’s current status for each indicator.

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Nursing Interventions – NIC Now that you have chosen your outcome for this patient, you will select the interventions that will best meet this outcome.

• If you have chosen the NOC, Respiratory Status: Gas Exchange continue below. • If you have chosen the NOC, Respiratory Status: Ventilation go to page 6. NOC - Respiratory Status: Gas Exchange The following two Nursing Interventions are appropriate for this patient. Review the activities listed below each NIC and select 5 that apply. Write these five on the nursing care plan in the activity column.

NIC: Acid-Base Management-Activities

(3, p.118)

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Maintain patent IV access

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Maintain patent airway

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Monitor hemodynamic status

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Monitor for respiratory pattern Provide mechanical ventilatory support

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Position to facilitate adequate ventilation Monitor determinants of tissue oxygen delivery Monitor determination of oxygen consumption

Monitor for worsening electrolyte imbalance Provide frequent oral hygiene

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Reduce oxygen consumption

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Promote orientation

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Monitor for loss of bicarbonate(e.g. fistula drainage & diarrhea)

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Administer prescribed alkaline medications based on ABG results

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Lynda/NNN/Case Study/Ped ICU 12/14/01

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Monitor ABG & electrolyte levels Monitor for symptoms of respiratory failure Provide oxygen therapy Obtain ordered specimen for lab analysis of acid-base balance Monitor neurological status Monitor for loss of acid( e.g. vomiting) Instruct pt &/or family on actions instituted to treat the acid-base imbalance

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NIC: Energy Management-Activities • •

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Determine pt’s physical limitations Determine causes of fatigue(e.g. treatments, pain & medications) Monitor/record pt’s sleep pattern & number of sleep hours Consult with dietitian about ways to increase intake of high-energy foods

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Set limits with hyperactivity when it interferes with others or with the pt Promote bedrest/activity limitation Use passive &/or active range of motion exercises to relieve muscle tension Assist pt to schedule rest periods

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Assist patient to sit on side of bed, if unable to transfer or walk Encourage physical activity

Instruct pt/SO to recognize signs & symptoms of fatigue that require reduction in activity Encourage pt to choose activities that gradually build endurance Assist pt/so to establish realistic activity goals

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(3, p.302)

Limit environmental stimuli to facilitate relaxation Monitor nutritional intake to ensure adequate energy resources Monitor pt for evidence of excess physical & emotional fatigue Arrange physical activities to reduce competition for oxygen supply to vital body functions (e.g. avoid activity immediately after meals) Determine what & how much activity is required to build endurance Encourage alternate rest & activity periods Provide calming diversional activities to promote relaxation Avoid care activities during scheduled rest periods

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Assist with regular physical activities

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Monitor pt’s oxygen response to self-care or nursing activities Instruct pt/so to notify health care provider if signs 7 symptoms of fatigue persist

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Assist pt to identify preferences for activity

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Encourage verbalization of feelings about limitation Determine pt’s/significant other’s perception of causes of fatigue Monitor cardio-respiratory response to activity Reduce physical discomforts that could interfere with cognitive function & selfmonitoring/regulation of activity Monitor location & nature of discomfort or pain during movement/activity Limit number of & interruptions by visitors Encourage an afternoon nap

Plan activities for periods when the pat has the most energy Monitor administration & effect of stimulant & depressants Assist pt to understand energy conservation principles Teach pt & significant other techniques of self-care that will minimize oxygen consumption Evaluate programmed increases in levels of activities

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NOC: Respiratory Status: Ventilation The following two Nursing Interventions are appropriate for this patient. Review the activities listed below each NIC and select 5 that apply. Write these five on the nursing care plan in the column labeled activities.

NIC: Airway Management-Activities

(3, p. 132)

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Open the airway, using chin lift or jaw thrust technique

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Position pt to maximize ventilation potential

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Insert oral or nasopharyngeal airway Encourage slow, deep breathing; turning; & coughing Auscultate breath sounds, noting areas of decreased or absent ventilation & presence of adventitious sounds Teach pt how to use prescribed inhalers Administer ultrasonic nebulizer treatments Position to alleviate dyspnea

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Perform chest physical therapy Instruct how to cough effectively Perform endotracheal or nasotracheal suctioning

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Administer humidified air or oxygen Monitor respiratory & oxygenation status

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Identify pt requiring actual/potential airway insertion Administer bronchodilators Assist with incentive spirometer Remove secretions by encouraging coughing or suctioning Regulate fluid intake to optimize fluid balance Administer aerosol treatments

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NIC: Mechanical Ventilation-Activities

(3,p.431)

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Collaborate with physician to use CPAP or PEEP to minimize alveolar hypoventilation

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Stop NG feedings during suctioning & 30-60 minutes before chest physiotherapy

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Monitor for decrease in exhale volume & increase in inspiratory pressure

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Initiate calming techniques

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Administer muscleparalyzing agents, sedatives, & narcotic analgesics Monitor ventilator pressure readings & breath sounds Monitor for adverse effects of mechanical ventilation: infections, etc. Perform chest physical therapy Provide oral care

Monitor pt’s progress on • current ventilator settings & make appro. changes Monitor for respiratory muscle • fatigue Promote adequate fluid & • nutritional intake Monitor degree of shunt, vital capacity, MVV, Vd/Vt, inspiratory force, & FEV1 for readiness to wean from mechanical ventilation, based on agency protocol

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Instruct pt & family about rationale & expected sensations associated with use of mechanical ventilators Monitor effectiveness of mechanical ventilator on pt’s physiological & psychological status Perform suctions Position to facilitate ventilation/perfusion matching Monitor for impending respiratory failure Monitor effects of ventilator changes on oxygenation

Congratulations! You have successfully completed your first nursing care plan using the standardized nursing language vocabularies of NANDA, NOC and NIC. 1. If you wish to received CE for this educational activity, please complete the evaluation form and return along with $10 to: Carol Williams, MS, RN, C Educational Services for Nursing University of Michigan Health System 300 North Ingalls, 6B12 Ann Arbor, Michigan 48109-0436 2. If you are working with a coordinator please give your quiz, evaluation and completed nursing care plan to your coordinator. Lynda/NNN/Case Study/Ped ICU 12/14/01

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Respiratory Status: Gas Exchange

Respiratory Status Ventilation

*IER = in expected range

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NURSING DIAGNOSIS

**WNL = within normal limits

Measurement Scale Score: 1 = Severe 2 = Substantial 3 = Moderate 4 = Slight 5 = None ❑ ease of breathing ❑ dyspnea at rest not present ❏ cyanosis not present ❑ neurological status IER ❏ restlessness not present ❏ fatigue not present ❏ Pao2 WNL** ❏ Paco2 WNL ❏ O2 saturation WNL DATE/TIME INITIALS

Measurement Scale Score: 1 = Severe 2 = Substantial 3 = Moderate 4 = Slight 5 = None ❏ respiratory rate IER* ❏ respiratory rhythm IER ❏ ease of breathing ❏ dyspnea at rest not present ❏ tidal volume IER ❏ vital capacity IER DATE/TIME INITIALS

NOCs (Outcomes)

Pediatric ICU Defining Characteristics (Signs & Symptoms) ❏ ❏ ❏ Related Factors (Etiology) ❏ ❏ ❏ ❏ ❏ ❏

Patient Name

ACTIVITIES:

DATE/TIME

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ACTIVITIES:

DATE/TIME

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DATE/TIME

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ACTIVITIES:

DATE/TIME

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OTHER INTERVENTIONS:

Airway Management

Acid-Base Management

Mechanical Ventilation

Energy Management

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NICs (interventions) ACTIVITIES:

SIGNATURE BOXES:

MODIFICATIONS:

MODIFICATIONS:

MODIFICATIONS:

MODIFICATIONS:

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