Question

- WRITE A CARE PLAN FOR A CLIENT WITH - ACUTE RESPIRATORY FAILURE (HYPOXIA OR HYPERCAPNIA)

(NOTE - CLIENT HAS A TRACH COLLAR IN PLACE AND ALSO COMPLAINED OF SEVERE SHORTNESS OF BREATH.)

- CLIENT HISTORY / DEMOGRAPHICS -

Male 40 y/o , Hispanic

Abdominal sepsis , diabetes type 2 , had a CODE BLUE event , client has pneumonia, HTN, ascites, peritonitis, client is lethargic.

- VITAL SIGNS -

Temp - 98.3 * c

Pulse - 67

RR - 20

BP - 154/83

Write a care plan -

3 Goals needed (long term and short term)

3 Nursing diagnosis with rationale

5 Nursing intervention for each Nursing Diagnosis.

Answer 1

1.Impaired gas exchange related to alveolar hypoventilation ,intrapulmonary shunting,V/Q mismatch ,and diffusion impairment as evidenced by hypoxaemia and/hypoxaemia.

Patient goal-Maintains adequate tissue oxygenation as indicated by normal/baseline arterial blood gases.

Nursing intervention

• Monitor respiratory and oxygenation status to detect systemic manifestations of decreased oxygen and increased carbondioxide.
• Initiate and maintain supplemental oxygen as prescribed,to increase PaO2 and SaO2 levels.
• Monitor the effects of position change on oxygenation.
• Monitor for symptoms of respiratory failure.
• Monitor determinants of tissue oxygen delivery.

2 Ineffective airway clearance related to excessive secretions,decreased level of consciousness,presence of an artificial airway,neuromuscular dysfunction ,and pain as evidenced by difficulty in expectorating sputum ,presence of bronchi ,ineffective or absent cough.

Goals-

Maintains effective airway with removal of excessive secretions.

Experiences normal or baseline breath sounds.

Nursing Interventions

• Encourage slow deep breathing ;turning;and coughing to promote secretion removal.
• Perform endotracheal or nasotracheal suctioning to remove secretions and improve oxygenation.
• Administer humidified air or oxygen to prevent drying of mucus.
• Perform chest physiotherapy to enhance removal of secretions.
• Regulate fluid intake to optimize fluid balance to liquify secretions.

3 Ineffective breathing pattern related to neuromuscular impairment of respirations,pain and anxiety ,decreased level of consciousness ,respiratory muscle fatigue,and bronchospasm as evidenced by respiratory rate <12 0r>24 b/min,altered I;E ratio,irregular breathing pattern ,use of accessory muscles ,asynchronous thoracoabdominal movement ,wheezing ,apnea

Patient goal

Demonstrates normal or baseline respiratory rate ,rythm, and depth of respirations.

Nursing Interventions

• Auscultate breath sounds ,noting areas of decreased or absent ventillation and presence of adventitious sounds to assess for presence of inability to sustain ventillation.
• Monitor for respiratory muscle fatigue to provide ventillatory support as needed.
• Position to minimize respiratory efforts to preserve energy for breathing.
• Teach pursed lip breathing techniques to reserve altered I:E ratio.
• Initiate resuscitation efforts because airway support maybe needed in the event of severely impaired ventilation or apnea.