Impaired Gas Exchange Case Study

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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

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