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    Care Plan Oxygenation

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    Joshua Mari Atienza Jareño
    Peripheral edema, body weight changes, skin and mucous membrane dryness, distended neck veins, blood pressure, pulse, lung sounds, skin turgor, appetite and gastrointestinal symptoms, thirst, urine output, and capillary refill can all indicate fluid volume excess or deficit and thus respond to IV fluid administration by improving or worsening based on whether excess or deficit is present. Behavioral changes may also occur with fluid imbalance or related acid-base disturbances.

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    Care Plan Oxygenation

    Uploaded by

    Joshua Mari Atienza Jareño
    224 views21 pages
    Peripheral edema, body weight changes, skin and mucous membrane dryness, distended neck veins, blood pressure, pulse, lung sounds, skin turgor, appetite and gastrointestinal symptoms, thirst, urine output, and capillary refill can all indicate fluid volume excess or deficit and thus respond to IV fluid administration by improving or worsening based on whether excess or deficit is present. Behavioral changes may also occur with fluid imbalance or related acid-base disturbances.

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    Peripheral edema, body weight changes, skin and mucous membrane dryness, distended neck veins, blood pressure, pulse, lung sounds, skin turgor, appetite and gastrointestinal symptoms, thirst, urine output, and capillary refill can all indicate fluid volume excess or deficit and thus respond to IV fluid administration by improving or worsening based on whether excess or deficit is present. Behavioral changes may also occur with fluid imbalance or related acid-base disturbances.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    224 views21 pages

    Care Plan Oxygenation

    Uploaded by

    Joshua Mari Atienza Jareño
    Peripheral edema, body weight changes, skin and mucous membrane dryness, distended neck veins, blood pressure, pulse, lung sounds, skin turgor, appetite and gastrointestinal symptoms, thirst, urine output, and capillary refill can all indicate fluid volume excess or deficit and thus respond to IV fluid administration by improving or worsening based on whether excess or deficit is present. Behavioral changes may also occur with fluid imbalance or related acid-base disturbances.

    Copyright:

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    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 21

    CARE PLAN

    OXYGENATION
    ASSESSMENT
    Mr. King’s physician diagnosed him with an
    upper respiratory infection. He is restless and
    anxious and has continuing dyspnea, and a
    productive cough, with dark yellow sputum.
    On auscultation there are audible expiratory
    wheezes, crackles, and diminished breath
    sounds over right lower lobe. His vital signs
    are pulse rate 120, temp 102 deg F, increased
    respiratory rate 36, BP 110/45 and an SpO2
    of 82%. As the day progresses Mary notices
    that his coughs are weaker, less sputum is
    produced, and Mr. King is becoming more
    fatigued.
    NURSING DIAGNOSIS

    Ineffective airway clearance


    related to increased
    secretions
    PLANNING
    GOAL EXPECTED OUTCOMES
     Pulmonary  Patient’s sputum will be clear,
    secretions will white and thinner consistency
    return to within 36hours.
    baseline levels  Patient’s lung sounds will be
    within 24 to 36 at baseline within 36 hours.
    hours.  Patient’s respiratory rate will
    be between 16 and 24 within
    24 hours.
     Patient will be able to clear
    airway secretions by coughing
    in 24 hours.
     Patient’s SpO2 will be >85%
    within 24 hours.
     Patient’s perceptions of
    dyspnea will improve.
    INTERVENTIONS
    AIRWAY MANAGEMENT RATIONALE
     Have Mr. King deep  A major complication of
    breathe and cough reduced mobility is
    every 2 hours while retention of pulmonary
    awake. secretions, which
    predisposes the patient to
    atelectasis & pneumonia.

     Have Mr. King  Ambulation, sitting


    change position upright and frequent
    frequently if in bed position changes are
    rest. If able, have him consistent with normal
    to sit up in a chair as activities and promote
    often as he is able to normal lung function and
    tolerate. mucociliary clearance.
     Encourage Mr. king  Fluid intake of
    to increase fluid 2800ml/24 hrs will
    intake to 2800ml/24 help liquefy
    hours if his cardiac secretions for easier
    condition does not removal. Caffeinated
    and alcoholic
    contraindicate it.
    beverages promote
    Avoid caffeinated diuresis and
    beverages and dehydration. Water
    alcohol; recommend is an effective
    water. expectorant, easily
    available & cost
    effective.
    EVALUATION
     Ask Mr. King about the color of his
    sputum.
     Auscultate lungs for adventitious lung
    sounds.
     Ask Mr. King to rate his perception of
    dyspnea, using a visual analog scale.
     Ask Mr. King if he is able to cough and
    expectorate his secretions.
     Obtain vital signs and SpO2 measures.
    Case
     Juan Paolo admitted to ER for
    morphine drug overdose. He is
    lethargic and stuporous; T98.9,
    P120, R13 and very shallow. ABG
    results: pH 7.28, PaCO2 49mm Hg
    and HCO3 25 mEq/l.
     Identify priority nursing diagnosis
    and interventions.
    ABG Interpretation
     Look at pH, normal 7.35-7.45
     Look at PaCO2. more than 45 mm
    Hg, less CO2 is being exhaled than
    normal.
     Look at HCO3, normal 22-26; with
    acidosis and retained CO2 is causing
    respiratory acidosis. Uncompensated.
    PHYSICAL SIGNS OF NUTRITIONAL STATUS
    Body Area Normal Appearance
     General appearance  Alert responsive
     Weight  Normal for height, age,

    body build
     Posture  Erect, arms and legs

    straight
     Muscles  Well-developed, firm,
    good tone, some fat under
    skin
     Nervous control
     Good attention span, not
    irritable or restless, normal
    reflexes, psychological
    stability
     Gastrointestinal  Good appetite & digestion,
    function normal regular elimination,
    no palpable (perceptible to
    touch) organs or masses

     Cardiovascular  Normal heart rate &


    function rhythm, no murmuring,
    normal BP for age

     General Vitality  Endurance, energetic,


    sleeps well, vigorous
     Hair  Shiny, lustrous, firm, not
    easily plucked, healthy scalp

     Skin (general)  Smooth, slightly moist,


    good color

     Face and neck  Skin color uniform,


    smooth, healthy appearance,
    not swollen

     Lips  Smooth, good color, moist,


    not chapped or swollen
    Mouth, oral  Reddish pink mucous
    mucous membranes in oral
    membranes cavity

     Gums  Good pink color,


    healthy, red no swelling
    or bleeding

     Tongue  Good pink color or


    deep reddish in
    appearance, not
    swollen or smooth,
    surface papillae present, no
    lesions
     Teeth  No pain, no sensitivity
     Eyes  Bright, clear, shiny, no
    sores at corner of eyelids,
    membranes moist and
    healthy pink color, no
    prominent blood vessels or
    mound of tissue or sclera,
    no fatigue circles beneath

     Neck (glands)  No enlargement


     Nails  Firm, pink

     Legs and feet  No tenderness, weakness or


    swelling; good color
     No malformations
     Skeleton
    CLINICAL
    FACTORS/CONDITIONS THAT
    RESPOND TO OR BE
    AFFECTED BY IV FLUID
    ADMINISTRATION
    a. Peripheral edema – a. Indicates expanded
    can interstitial volume. This
    be rated for severity by is usually most evident
    assessing pitting over in dependent areas (i.e.,
    bony prominences. 1+ feet and ankles). Fluid
    indicates barely overload will worsen
    detectable Edema.
    edema to 4+ for deep
    persistent pitting

    b. Daily weights
    b. Body weight
    document fluid retention
    or loss. Change in body
    weight of 1kg
    corresponds to 1L of
    fluid retention loss.
    c. Dry skin and c. Suggests fluid volume
    mucous deficit.
    membranes
    d. Distended d. Suggests fluid volume
    neck veins excess.

    e. Blood e. Elevated BP indicates


    pressure volume excess due to
    changes increase in stroke volume.
    Decreased BP indicates
    fluid volume deficit due to
    a decrease in stroke
    volume
    f. Irregular pulse f. Rhythm changes
    rhythm; occur with potassium,
    increased pulse calcium, and/or
    rate magnesium
    abnormalities; rate
    change occurs with fluid
    volume deficit

    g. Auscultation g. May signal fluid build


    crackles or up in the lungs due to
    rhonchi in lungs fluid volume excess
    h. Inelastic skin h. With fluid volume
    turgor (after deficit, the pinched
    pinching, fails to skin stays elevated
    return to normal for several seconds.
    position within 3
    seconds i. May occur with
    i. Anorexia, nausea acute fluid volume
    and vomiting deficit or fluid
    volume excess.

    j. Thirst j. Symptomatic of
    fluid volume deficit
    k. Decreased k. During dehydration, kidney
    urine output attempts to restore fluid balance
    by reducing urine production.
    Average daily adult urine output
    is 1500ml; urine output of less
    than 400ml/24 hr (oliguria)
    signals the retention metabolic
    Wastes.

    l. Behavioral l. May occur with fluid volume


    changes (e.g., deficit or acid-base imbalance
    restlessness,
    confusion)

    m. Decreased m. May suggest poor tissue


    capillary refill perfusion due to fluid deficit

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