Problem:
Nursing Diagnosis
NANDA:
Impaired gas exchange
Etiology(R/T):
COPD
Signs & Symp-toms (AEB)
SUBJECTIVE:
Dyspnea
Abnormal breathing
-Patients states when she tries to get up she gets tired quickly.
OBJECTIVE:
-Abnormal ABG values.
-Change in Vital signs.
-Increased Respiratory rate of 29.
-Patient RR is labored and uneven.
-Patient uses BIPAP. SHORT TERM goal/s:
-Pt will show effective coughing and deep breathing exercise by end of 8 hour shift.
LONG TERM goal/s:
-Patient will quit smoking.
-Patient will verbalize the understanding of how to maintain patent airway.
NOTE: You need 3 separate nursing diagnoses with corresponding Interventions, Rationales, and Evaluations. #1
-Assess and record patient respiratory rate and
#4
Auscultated lung sounds, to monitor decreased airflow.
(RELATED TO LONG-TERM GOALS)
#5
Evaluate how much physical activity patient can tolerate. Provide calm, quiet environment for the patient. Limit patient’s activity/encourage bed or chair rest during acute phase. Have the patient resume activity slowly and as tolerated. #1
Assess when patient in respiratory distress/ how the chronic is the disease process.
#2 When the patients is in upright position and oxygen delivery is improved and it helps to decrease airway collapse, dyspnea, and work of breathing.
#3 Monitor for cyanosis it can be around the nailbeds or around lips.
-Duskiness and cyanosis can indicated hypoxemia.
#4
Lung sounds can be weak due to decrease of airflow.
-Wheezes can indicate bronchospasm or retained secretions.
-If we hear crackles it can indicate interstitial fluid or cardiac decompensation.
#5
If the patient is in severe respiratory distress it may be hard for her to perform self-care due to hypoxemia and dyspnea. Rest is important part of patient diagnosis. Exercise program can help the patient with increasing endurance and strength without causing severe dyspnea and can improve sense of
The primary survey intends to rapidly and systematically establish and treat any life threatening, follow the ABC principles: airway, breathing, and circulation. Prioritise according to the severity of their injury. Unresponsive casualties are at great risk.
Additionally, the clinical staff has shown very low level of confidence in the RR documentation on observation chart. Lack of time, laziness, lack of training and knowledge and unawareness of the importance of the respiratory assessment are main reasons to neglect this important aspect of nursing as stated in this study (Philip, Richardson, & Cohen,
Duerden, M. & Price, D. (2001). Training issues in the use of inhalers. Practical Disease
A total of 22 patients were admitted for the study, with 11 on the BiPAP side and the other half on the BiPAP using the AVAPS. Every patient had to be in a select range of APACHE II score within 4, age within 10, pH within.04, Glasgow Coma Scale within 2, and BMI within 2 points; also referred by a doctor who did not know about the study. Both of the groups received the same parameters for their BiPAP machines, including an IPAP of 12 cmH2O, EPAP as 6 cmH2O, a tidal volume 8-12 ml/kg of ideal body weight, respiratory rate of 15 bpm, rise time 300-400 ms, and finally Helsinki-based inspiration time at a minimum of.6 seconds. Arterial blood gases, maximum tidal volumes and IPAP, EVT, leaks, respiratory and heart rates, and blood pressure were all assessed every 1, 3, 12, and then every 24 hours.... ... middle of paper ... ...
One of the pivotal roles of a nurse is the ability to recognise patient deterioration. The skill of identifying crucial elements of deterioration and acting appropriately is fundamental for positive patient outcome. A vital skill performed primarily by nurses is the act of respiratory rate measurement. This skill is performed in addition to five other physiological parameters, which form a basis for a scoring system. The scoring systems commonly used are known as NEWS (National Early Warning Score) and EWS (Early Warning Score). As many adverse events are preceded by a period of time where by the patient exhibits physiological dysfunction, there is often time to correct abnormalities. This has significance for nurses, as they are responsible
...so discuss making a exercise plan that will work for the patient, and will not cause him/her any pain. If all of the correct measures are taken, and the patient is taking care of themselves, they can prevent more serious complications from occurring. They must know that they are serious complications from one not taking care of themselves, or living a unhealthy life style. It does involve a lifelong commitment to change. Medication will help, but one must also be willing to change.
Breathing is the most important AL (Roper et al, 1998). A detailed assessment of her airway would be performed because protection of the airway throughout anaesthesia is essential (Yates, 2000). This does not just include recording of respiration rate and oxygen saturation (SpO2) but also noting any use of accessory muscles, shortness of breath, auscultation of chest and lungs areas for wheezes/crackles and asking patient about history of any respiratory illness/smoking (McArthur-Rouse, 2007).
HENDERSON, Y (1998) A practical approach to breathing control in primary care. Nursing Standard (JULY) 22 (44) p41
An electrocardiogram (ECG) is one of the primary assessments concluded on patients who are believed to be suffering from cardiac complications. It involves a series of leads attached to the patient which measure the electrical activity of the heart and can be used to detect abnormalities in the heart function. The ECG is virtually always permanently abnormal after an acute myocardial infarction (Julian, Cowan & Mclenachan, 2005). Julies ECG showed an ST segment elevation which is the earliest indication that a myocardial infarction had in fact taken place. The Resuscitation Council (2006) recommends that clinical staff use a systematic approach when assessing and treating an acutely ill patient. Therefore the ABCDE framework would be used to assess Julie. This stands for airways, breathing, circulation, disability and elimination. On admission to A&E staff introduced themselves to Julie and asked her a series of questions about what had happened to which she responded. As she was able to communicate effectively this indicates that her airways are patent. Julie looked extremely pale and short of breath and frequently complained about a feeling of heaviness which radiated from her chest to her left arm. The nurses sat Julie in an upright in order to assess her breathing. The rate of respiration will vary with age and gender. For a healthy adult, respiratory rate of 12-18 breaths per minute is considered to be normal (Blows, 2001). High rates, and especially increasing rates, are markers of illness and a warning that the patient may suddenly deteriorate. Julie’s respiratory rates were recorded to be 21 breaths per minute and regular which can be described as tachypnoea. Julies chest wall appeared to expand equally and symmetrical on each side with each breath taken. Julies SP02 levels which are an estimation of oxygen
...e cured, but the course of the disease can be influenced by optimal medical treatment and interprofessional pulmonary rehabilitation (PR), which includes exercise as one of its cornerstones” (Hellem, Bruugsgaard, & Bergland, 2012, p. 206).
Continue by giving two slow breaths, one to one and a half seconds per breath. Watch for the chest to rise, and allow for exhalation between breaths. Check for a pulse. The carotid artery, on the side of the neck, is the easiest and most accessible. If breathing remains absent, but a pulse is present, provide rescue breathing, rescue breathing is one breath every three seconds.
Hess Dean R., M. N. (2012). Respiratory Care: Principles and Practice 12th Edition. Sudbury, MA: Jones and Bartlett Learning.
Hinkle, Janice, and Kerry Cheever. “Management of Patients with Chronic Pulmonary Disease." Textbook of Medical-Surgical Nursing, 13th Ed. Philadelphia: Lisa McAllister, 2013. 619-630. Print.
Physiotherapy in the ICU is a separate specialty. The clinical decision in this area is based on three main principals: a) knowledge of underlying pathophysiology and base for general care, b) normal and scientific evidence for therapeutic interventions, c) clinical experience.
There are 2 types of breathing, costal and diaphragmatic breathing (Berman, 2015). Costal refers to the intercostal and accessory muscles while diaphragmatic refers to breathing using your diaphragm (Berman, 2015).It is important to understand the two different types of breathing because it is vital in the assessment of the patient. For example, if a patient is suing their accessory muscles to aid in breathing then we can safely assume that they are having breathing problems and use a focused assessment of their respiration. Assessing respiration is fairly straightforward. The patient’s respiration rate can be affected by anxiety so a useful to avoid this is to check pulse first and after you have finished that, while still holding their pulse point, check their respiration rate. Inconspicuous assessment avoids the patient changing their breathing because they know they are being assessed which patients can sometimes do subconsciously. Through textbooks and practical classes I have learned what to be aware of while assessing a patient’s respiratory rate. For example; their normal breathing pattern, if and how their health problems are affecting their breathing, any medications that could affect their respiratory rate and also the rate, depth, rhythm and quality of their breathing (Berman, 2015). The only problem I found while assessing respiration rate was I thought it seemed a bit invasive looking at the