Question

 You are assigned to care for a 72-year-old woman with severe emphysema. Today she was walking at a mall when she suddenly grabbed her right side and gasped, "Oh, something just popped" She whispered to her walking companion,

 I can't get any air" Her companion yelled for someone to call 911 and helped her to the nearest bench. By the time the rescue unit arrived, she was stuporous and in severe respiratory distress. She was intubated, started on intravenous lactated Ringer's at KVO (keep vein open, and transported to the nearest emergency department (ED). On arrival at the ED, you auscultate muffled heart tones, no breath sounds on the right, and faint sounds on the left. She is stuporous, tachycardiac, and cyanotic. The paramedics inform you that it was difficult to ventilate her. A portable chest x-ray (CXR) examination shows an 80% pneumothorax on the right.

 Arterial Blood Gases (ABGs) on 100% 02: pH 7.25 Paco2 92 mm Hg Pao2 32 mm Hg HCO3 27 mmol/L Spo2 53%

 4. it is now the end of your shift and her condition has stabilized. Using the SBAR framework, describe the bedside change-of-shift report you will give the oncoming nurse.

 5. What are some appropriate nursing diagnoses for this client?

 6. What are some nursing interventions that you would provide based on the above lab values?

Answer 1

4. End of the shift nurse should hand over the patient details like ABG blood analysis and it's value. Inform the ABG results at the time of admission and inform the patients preview health condition, and their medication history ,Inform the incident of the respiratory distress presence and also inform the physician orders to the next shift nurse for further treatment.

5.NURSING DIAGNOSIS,

Ineffective breathing pattern

Impaired gas exchange

Ineffective airway clearance

Aspiration

Decreases cardiac output

Excess fliud volume

Impaired physical mobility

Ineffective coping etc..

Some interventions for respiratory distress condition of the client ;

Assess o2 saturation level every 30 months once

Provide the comfortable position to the client

Provide adequate nutrition

Maintain patient airway

Demonstrate the breathing exercises to the client

Evaluate ABG values periodically

Do an complete respiratory assessment for further treatment

Provide intubatuon

Prevent the ventilation acquired pneumonia

Provide oral care every 2 hrs once..

Administer medications.