Nursing Care Plan 6 Impaired Gas Exchange

Case Scenario # 3 Adult ICU INSTRUCTIONS: For this case study, 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.

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Patient is a 58-year-old man admitted to a medicine unit one week ago with a diagnosis of atypical pneumonia. He was doing fine yesterday on O2 6L by NC. Time 7am-12noon 12noon 1500

Arrival in CCMU 1515

1525 Post Intubation 1530 Post-suctioning

1535

1545 Next 2 hours 1545-1745

1745-1845 Next hour 1850

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Vital Signs/Data Urine Output = 0 ml Requires increasing FiO2 PO2 – 85% (on 100% rebreather mask) • minimally moving air • using accessary muscles for breathing • Unresponsive, • Breathing at 45 breaths/min, • Cyanotic, • Cold, mottled skin, • Pedal pulses heard only by Doppler, • Generalized edema. • Rhythm = ST with a rate of 120. • BP = 96/58. • Temp = 96.6 axillary SPO2 drops to 70%. SPO2 increases to 90%. First ABG = 9065-45-7.42-26. Resp. rate = 14. His suction requirements become minimal • BP drops to 57/36.

Intervention/Tx

Lasix 40 mg IVP at 12noon Tx to CCMU

Response

O = 800 ml

Etomidate for the intubation • Intubated w/ #8 Shiley • Vent Settings: 100% FiO2, AC 14, and VT 650.

He is immediately suctioned for thick tan secretions, copious amounts.

Immediately • Given 2.5 liters of 0.9% saline IV • Started on Dopamine at 20 mcg/kg/min.

His BP responded to 120/75. Dopamine is titrated down to 10 mcg/kg/min IV fluid is decreased to 150 cc/hr. Bilateral soft wrist restraints were applied As he became more responsive, he began reaching for his ETT • BP increased • Became alert & oriented x 3 • Understood explanations given to him. The restraints were removed.

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Functional Health Patterns* Ø The Functional Health Patterns that are relevant for this gentleman are: Activity-Exercise Cognitive-Perceptual Health Perception-Health Management Ø Activity-Exercise is the most affected functional health pattern for this gentleman.

* 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; Activity-Exercise; Sleep/Rest; Self-Perception/SelfConcept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief.

Choosing the Nursing Diagnosis (es) These nursing diagnoses are appropriate for this patient. In practice, you may select additional nursing diagnoses. Nursing Diagnosis: Impaired Gas Exchange Defining Characteristics: dyspnea, decreased O2 saturation despite high FIO2, unresponsiveness, and cyanosis Related Factors: atypical pneumonia and possible pulmonary embolus. Nursing Diagnosis: Decreased Cardiac Output Defining Characteristics: low BP, cyanosis, rapid heart rate, and unresponsiveness Related Factors Etiology: hypovolemia (he had received Lasix. Decreased BP is common with the initiation of positive pressure ventilation causing decreased venous return to the heart especially in the face of hypovolemia) or Entomidate side effect (minimal risk).

Ø While both nursing diagnoses are appropriate, for purposes of this exercise let’s use

Impaired Gas Exchange. Ø On the nursing care plan form write in the nursing diagnosis, identifying the defining characteristics and related factors.

Adult ICU Medicine

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Choosing the 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 gentleman.

Nursing Outcome(s) 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 Tidal volume IER Vital capacity IER *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. Now that you have chosen your outcome for this gentleman, you will select the interventions that will best meet this outcome.

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Choosing the Nursing Interventions - NIC • If you have chosen the NOC, Respiratory Status: Gas Exchange continue below. • If you have chosen the NOC, Respiratory Status: Ventilation go to that section and select your interventions and activities.

NOC - Respiratory Status: Gas Exchange The following two Nursing Interventions, Acid – Base Management and Energy Management are appropriate for this gentleman. Review the activities listed below each NIC and select 5 activities that apply. Write these five on the nursing care plan in the activity column respectively for Acid-Base Management and Energy Management. NIC: Acid-Base Management3(pg.118) •

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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Adult ICU Medicine

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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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Again, review the activities listed below the NIC and select 5. Write these five on the nursing care plan in the activity column for Energy Management. NOC: Respiratory Status: Gas Exchange NIC: Energy Management3 (pg.302) 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 Assist patient to sit on side of bed, if unable to transfer or walk Encourage physical activity

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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 relaxa6tion Avoid care activities during scheduled rest periods 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 understand energy conservation principles

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Teach pt & significant other techniques of self-care that will minimize oxygen consumption

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Assist pt to limit daytime sleep to providing activity that promotes wakefulness

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Evaluate programmed increases in levels of activities

Instruct pt/SO to recognize • signs & symptoms of fatigue that require reduction in activity • Assist pt to identify task that • Assist pt to self-monitor by family & friends can perform developing & using a written in the home to prevent/relieve record of calorie intake & fatigue energy expenditure • Encourage pt to choose • Assist pt to identify activities that gradually build preferences for activity endurance Assist pt/so to establish realistic activity goals •

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Encourage verbalization of feelings about limitation Determine pt’s/significant other’s perception of causes of fatigue

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Monitor cardiorespiratory response to activity

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Reduce physical discomforts that could interfere with cognitive function & selfmonitoring/regulation of activity

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Monitor location & nature of discomfort or pain during movement/activity Limit number of & interruptions by visitors Encourage an afternoon nap

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Plan activities for periods when the pat has the most energy Monitor administration & effect of stimulant & depressants

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NOC: Respiratory Status: Ventilation • Select 5 nursing activities that are appropriate for this patient and write them on the care plan in the activity column for Airway Management. NIC: Airway Management: Activities3(pg.132) •

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

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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

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

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Administer ultrasonic nebulizer treatments Position to alleviate dyspnea

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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

NIC: Mechanical Ventilation: Activities3 (pg. 431) •

Monitor for respiratory muscle fatigue

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Monitor for impending respiratory failure

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Monitor for decrease in exhale volume & increase in inspiratory pressure Initiate calming techniques

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Provide oral care

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Monitor ventilator pressure readings & breath sounds Monitor for adverse effects of mechanical ventilation: infections, etc. Perform chest physical therapy

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Monitor effects of ventilator changes on oxygenation: ABG, SaO2, SvO2, end-tidal CO2, Qsp/Qt & A-aDO2 levels & pt’s subjective response intake

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Monitor pt’s progress on • current ventilator settings & make appropriate changes Collaborate with physician to • use CPAP or PEEP to minimize alveolar hypoventilation • Monitor degree of shunt, vital capacity, MVV, Vd/Vt, inspiratory force, & FEV1 for readiness to wean from mechanical ventilation, based on agency protocol Promote adequate fluid & nutritional

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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 Position to facilitate ventilation/perfusion matching Stop NG feedings during suctioning & 30-60 minutes before chest physiotherapy Perform suctioning, based on adventitious sounds &/or ventilatory pressures Administer muscle-paralyzing agents, sedatives, & narcotic analgesics

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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.

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Related Factors (Etiology) ❏ ❏ ❏

*IER = in expected range

**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

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Respiratory Status: Gas Exchange

Respiratory Status Ventilation

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)

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Defining Characteristics (Signs & Symptoms) ❏ ❏ ❏

NURSING DIAGNOSIS

Adult ICU

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Patient Name

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Adult ICU Medicine

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Airway Management

Acid-Base Management

Mechanical Ventilation

Energy Management

NIC (interventions)

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OTHER INTERVENTIONS:

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ACTIVITIES:

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SIGNATURE BOXES:

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