ARF ARF

Present Health History

Present Health History

Past Health History

Past Health History

• Chronic Obstructive Pulmonary Disease (COPD)
• No prior history of hospitalizations and surgery noted.

Gordon's Functional Health Pattern

Health Perception

Health Management

Diagnosed with Chronic Obstructive Pulmonary Disease 4 years ago

DAY 4

ABG

pH 7.32 decreased

PaCO2 49 mmHg increased

PaO2 50 mmHg decreased

HCO3 – 30 mEq/L increased

O2 Sat: 80%

RR: 38 bpm

Shortness of breath

Tachypnea

Tachycardia

Diaphoresis

Use of accessory muscles to breathe

Hypercarbia

Hypoxia

Confusion

Nasal flaring

Flail Chest

3rd day:

Subjective: Patient complained of shortness of breath

Objective:

ABG is as follows:

pH – 7.35

PaCO2 – 36 mmHg

PaO2 – 60 mmHg (Below normal average)

HCO3- 24 mEq/L

CXR - Left sided consolidation

Decreasing level of consciousness

Delayed CRT (capillary refill time)

Excessive mucous secretions

Diaphoresis

Tachypnea

Shortness of breath

Risk for fall related to alteration in cognitive functioning

Risk for infection related to decreased ciliary action (increased mucus production

Nutrition Metabolic

Objective:

Increased diaphoresis

Given IV morphine sulfate and epidural anesthesia

No Alterations for this pattern

Activity - Exercise

Diagnosed with Chronic Obstructive Pulmonary Disease 4 years ago

Riding his motorcycle for supplies, he crashed on a nearby vehicle sustaining a left flail chest

DAY 4

ABG

pH 7.32 decreased

PaCO2 49 mmHg increased

PaO2 50 mmHg decreased

HCO3 – 30 mEq/L increased

O2 Sat: 80%

RR: 38 bpm

Shortness of breath

Tachypnea

Tachycardia

Diaphoresis

Use of accessory muscles to breathe

Hypercarbia

Hypoxia

Confusion

Nasal flaring

Flail Chest

3rd day:

Subjective: Patient complained of shortness of breath

Objective:

ABG is as follows:

pH – 7.35

PaCO2 – 36 mmHg

PaO2 – 60 mmHg (Below normal average)

HCO3- 24 mEq/L

CXR - Left sided consolidation

Decreasing level of consciousness

Delayed CRT (capillary refill time)

Excessive mucous secretions

Diaphoresis

Tachypnea

Shortness of breath

Impaired gas exchange related to alveolar hypoventilation and V/Q mismatch amb, Respiratory acidosis in ABG, 80% O2 sat

Ineffective airway clearance related to excessive secretions amb SOB, 38bpm RR,

Ineffective breathing pattern related to hypoventilation amb use of accessory muscles to breathe and RR of 38bpm

Impaired spontaneous ventilation r/t respiratory muscle fatigue amb tachypnea, accessory muscle use and 80% SaO2

Ineffective cerebral tissue perfusion related to hypercarbia and hypoxemia amb PaCO2 49 mmHg increased, PaO2 50 mmHg decreased, decreasing level of consciousness and confusion

Cognitive - Perceptual

Objective

Left Flail chest

IV Morphine sulfate and epidural anesthesia

Decreasing level of consciousness

Confused and hypoxic

Acute confusion related to hypercarbia and hypoxemia amb PaCO2 49 mmHg increased, PaO2 50 mmHg decreased, decreasing level of consciousness and confusion

LEFT Flail Chest

Increased mucous secretion

Increased RR (tachypnea) - 38bpm

shortness of breath

Physical Assessment

Delayed capillary refill time

Increasing hypercarbia and hypoxia

Use of accessory muscles to breathe

nasal flaring,

intercostal muscle retraction

Tachycardia

Increased diaphoresis

Confusion

Decreasing level of consciousness

3rd Day ABG

Parameter

Result

Analysis

pH

7.35

Normal

ABG 1

PaCO2

36 mmhg

Normal

PaO2

60 mmhg

Decreased

Normal

HCO3

24 meq/L

MILD Hypoxemia

3rd Day ABG

Parameter

Result

Analysis

pH

7.32

Decreased

ABG 2

PaCO2

49 mmhg

Increased

PaO2

50 mmhg

Decreased

Increased

HCO3

30 meq/L

COMPENSATED RESPIRATORY ACIDOSIS with MODERATE HYPOXEMIA

Chest X-Ray Day 3

Left Sided Pulmonary Consolidation

CXR

Epidural Anesthesia

Epidural anesthesia

Adequate analgesia in patients with thoracic trauma

improves respiratory function by allowing the patient

to breathe adequately, cough and cooperate with chest physiotherapy

Nursing Care Plans

• Ineffective airway clearance related to excessive secretions amb SOB, 38bpm RR,
• Ineffective breathing pattern related to hypoventilation amb use of accessory muscles to breathe and RR of 38bpm
• Impaired gas exchange related to alveolar hypoventilation and V/Q mismatch amb, Respiratory acidosis in ABG, 80% O2 sat

Ineffective airway clearance related to excessive secretions as manifested SOB, 38bpm RR

Independent

Assessment

Planning

• Get and monitor the pt’s vital signs for baseline data.
• Assess for the patency, auscultate for lung sounds and distinguish the abnormal breath sounds.
• Assess the client's respirations and note the quality, pattern, and depth. Also note if the client is experiencing nasal flaring and use of accessory muscles for breathing.
• Assess for the mental status.
• Monitor the pt’s pulse oximetry.
• Teach the patient about proper coughing and breathing to effectively excrete retained secretions after recovery.
• Position the client for a more effective breathing, if the pt is able to position in sitting position or upright this is ideal.
• Provide oral care at least every 4 hours.

DAY 4

• ABG - RESPIRATORY ACIDOSIS
• pH 7.32 decreased
• PaCO2 49 mmHg increased
• PaO2 50 mmHg decreased
• HCO3 – 30 mEq/L increased
• O2 Sat: 80%
• RR: 38 bpm
• Shortness of breath
• Tachypnea
• Tachycardia
• Diaphoresis
• Use of accessory muscles to breathe
• Hypercarbia
• Hypoxia
• Confusion
• Nasal flaring

Short term goal:

By the end of 8 hours of the nursing interventions the pt will be able to achieve airway patency

Long term goal:

By the end of 1 week of the nursing interventions the pt will be able to manifest a clear, open airway as evidenced by normal breathing pattern, rate and depth of respirations.

Short term goal:

By the end of 8 hours of the nursing interventions the pt achieved airway patency with clear breath sounds

Long term goal:

By the end of 1 week of the nursing interventions the pt was able to manifest a clear, open airway as evidenced by normal breathing pattern, with RR ranging from 16-20bpm

Dependent

Collaborative

• Give medications such as antibiotics, mucolytics, bronchodilators, expectorants as needed.
• Encourage incentive spirometry.
• Give/maintain oxygen as ordered.
• Perform nasotracheal suction as needed and as ordered.
• If secretions cannot be cleared, consider intubation.
• If the pt is unable to drink water orally provide IV hydration as prescribed

• Coordinate/collaborate with a respiratory therapist for chest physiotherapy if the client is still having a hard time breathing.
• If the client’s symptoms worsens refer to the physician

Ineffective Breathing pattern related to hypoventilation as manifested by use of accessory muscles to breathe and RR of 38bpm

Assessment

Planning

Evaluation

After 8 hours of the successful nursing interventions the patient was able to maintain effective respiratory pattern via oxygen administration through nasal cannula without the use of accessory muscles as evidenced by relaxed breathing at RR of 20BPM

Long Term:

After 3 days of nursing interventions the patient will be able to reestablish and maintain effective respiratory pattern via oxygen administration through nasal cannula without the use of accessory muscles and other signs of hypoxia as evidenced by PO2 of 85-95mmhg and RR ranging from 16-20bpm

Subjective:

Complains of Shortness of breath

Objective:

• Use of accessory muscles noted
• Respiratory rate of 38bpm
• Nasal Flaring
• Intercostal muscle retraction

ABG:

• pH 7.32
• PaCO2 49 mmHg
• PaO2 50 mmHg
• HCO3 – 30 mEq/L

Short term:

After 8 hours of nursing interventions the patient will be able to maintain an effective breathing pattern as evidenced by relaxed breathing at normal rate and absence

Long Term:

After 3 days of nursing interventions the patient will be able to reestablish and maintain effective respiratory pattern via oxygen administration through nasal cannula without the use of accessory muscles and other signs of hypoxia

Independent

Dependent:

1.Administer medication as ordered by the physician such as Morphine Sulfate

Collaborative:

Collaboration with the Respiratory Therapist for oxygen therapy

• Maintain a calm attitude when dealing with the client
• Assess and record patient’s respiratory rate at least every 4 hours
• Monitor ABG levels, according to facility policy
• Observe for breathing patterns
• Assess for use of accessory muscles
• Keep away from high concentration of oxygen in patients with COPD (Chronic Obstructive Pulmonary Disease)
• Monitor patient’s O2 saturation using pulse oximeter
• Suction secretions, as necessary
• Position patient with proper body alignment for optimal breathing pattern

Impaired gas exchange r/t alveolar hypoventilation and V/Q mismatch as manifested by respiratory acidosis in ABG, 80% O2 sat

Assessment

Planning

Evaluation

Subjective: complained of shortness of breath

Objective:

DAY 4

ABG - RESPIRATORY ACIDOSIS

• pH 7.32 decreased

• PaCO2 49 mmHg increased

• PaO2 50 mmHg decreased

• HCO3 – 30 mEq/L increased

• O2 Sat: 80%

• RR: 38 bpm

• Shortness of breath

• Tachypnea

• Tachycardia

• Diaphoresis

• Use of accessory muscles to breathe

• Hypercarbia

• Hypoxia

• Confusion

• Nasal flaring

Short term:

After 8 hours of nursing intervention. Patient maintained oximetry results within normal range at 96-98%, blood gases within normal range, and baseline HR (85) and RR (18) for the patient.

Long term:

At the end of 3 days nursing intervention, patient was able to maintain clear lung fields and remains free of signs of respiratory distress

Short term:

At the end 8 hours of nursing intervention. Patient maintains oximetry results within normal range, blood gases within normal range, and baseline HR for the patient.

Long term:

At the end of 3 days nursing intervention, patient will be able to maintain clear lung fields and remains free of signs of respiratory distress

Independent

Dependent:

• Administer sedatives, and opioid analgesics as ordered.
• Maintain an oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater

Collaborative:

• Instruct family in complications of disease and importance of maintaining medical regimen, including when to call a physician.
• For postoperative patients, assist with splinting the chest.

• Assess respiratory rate, depth, and effort, including the use of accessory muscles, nasal flaring, and abnormal breathing patterns.
• Regularly check the patient’s position so that he or she does not slump down in bed.
• Position patient with head of bed elevated, in a semi-Fowler’s position as tolerated.
• Watch for onset of hypoventilation as evidenced by increased somnolence* after initiating or increasing oxygen therapy
• Suction as necessary.
• Monitor the effects of sedation and analgesics on patient’s respiratory pattern
• Turn the patient every 2 hours. Monitor mixed venous oxygen saturation closely after turning.
• Pace activities and schedule rest periods to prevent fatigue. Assist with ADLs.
• Schedule nursing care to provide rest and minimize fatigue