Ineffective Breathing Pattern

A case study: A 76 years old woman with Impaired gas Exchange aeb spO2 85%
Feden Flor Ignacio
N00766446
March 11, 2014
NURS 252
Professor John Stone
Thursday group
Humber College

Introduction
The purpose of my paper is to create nursing interventions from a case study of a 76 year old female who
was admitted to respiratory medical unit with influenza. My priority was the patient's low level of oxygen
saturation of 85%. I will include the pathophysiological priorities and clinical manifestations. The

patient had past history of myocardial infarction 2 years ago. She also has congestive heart failure,
peripheral vascular disease. Her chief complaint was present with dry, hacking, non-productive cough.
Complains of weakness, muscle pain, and severe fatigue. Auscultation revealed significant amount of fine
crackles to bases. Decreased air to left lower lobe. Vital signs are as follows T 37.3 C, Pulse 130 irregular
rhythm, R 28, BP 114/84, O2 sat 85% on room air and she denies pain.
Pathophysiological Priority
The common respiratory failure happens when there is insufficient exchange of oxygen and carbon
dioxide to meet metabolism of the body (Jarvis, 2014). Complete assessment of the respiratory system
helps explore present and potential respiratory problems. Based on the patient's history, the priority
nursing diagnosis was impaired gas exchange as evidence by decreased O2 sat of 85% and irregular pulse
rhythm 130. There is a study linked between cardiovascular condition may associated with pulmonary
edema (Ayus, Varon & Arieffe, 2000). Pulmonary edema occurs when the patients accumulate fluids in
the lungs as evidenced of fine crackles to bases. There is inflammatory response in the tissue of the lungs.
Indication of damage to the surfactant of the lungs that can lead to alveoli collapsed further impairing gas
exchange. The patient respiratory increases and sufficient oxygen cannot enter the circulation. Oxygen
saturation will decreased as evidence in the patient's vital signs. In these case study there is a leakage of
fluids from the pulmonary capillaries resulting to pulmonary edema. The patient had history of heart
failure and her heart muscle is unable or too weak to pump up blood sufficiently that caused accumulation
of fluids in the lungs (Ezzone, 2007).
Clinical Manifestation
One of the symptoms of pulmonary edema is hypoxemia, insufficient level of oxygen in the blood as
evidence of low saturation level of less than 90% (Page, 2013). Secondly, the patient body will
experienced rapid breathing or irregular pulse as the need to attempt to get oxygen into the body (Volsko,
2013). On auscultation, the crackles were present due to fluids build up in the lungs. Lastly, the evidenced

of decreased breath sounds as it is harder to hear through fluid in patient's alveoli. In addition, due to lack
of oxygen the body may experience weakness and fatigue.
Interventions/ Treatment
According to Volsko, there is a various interventions to enhance airway breathing and improve lung
exchange (2013). Here are the priority interventions; administer oxygen as ordered to maintain an
acceptable level of oxygen which is 96% and above (Sanders, 2012). Nurses should assess the respiratory
rate of the patient at least every four hours to detect early stages of respiratory failure. Auscultation of
breath sounds to decreased adventitious breath sounds and the nurses can report changes immediately
(Sanders, 2012). Patient teaching about maintaining adequate hydration and the need to remain active as
possible. Moreover, explain to the patients the importance of doing deep breathing and coughing exercise
to fully expand the lungs and try to enhance expelling the mucous (Lengkapku, 2013). Lastly,
consultation with appropriate healthcare provider like respiratory therapies and physician to order x-rays
and laboratory testing to rule out pulmonary edema or any respiratory disease (Page, 2013).
Conclusion
Influenza can lead to different respiratory failure and in these case the patient, present buildup of fluids in
the lungs which is pulmonary edema due to long history of cardiovascular problems. Respiratory distress
that caused low saturation level of the patient. As a result, the patient irregular heart beat compensate the
lack of oxygen in the body. Moreover, procedure such as CT scan, x-rays and laboratory testing to rule
out pulmonary edema and nurses will understand patients condition. Understanding and identifying any
trend of deterioration to the patient's status. Continues monitoring will also be implemented by the
nursing staff to monitor any changes. Overall, a detailed nursing interventions can help the health care
staff to provide the better care for this 76 years old woman.

Reference
Ayus JC, Varon J, Arieff AI. Hyponatremia, Cerebral Edema, and Noncardiogenic Pulmonary Edema in
Marathon Runners. Ann Intern Med. 2000; 132:711-714. Doi: 10.7326/0003- 4819-132-9-20000502000005
Ezzone S. A Pulmonary Edema. Clinical Journal of Oncology Nursing (2nd ed., pp. 213-217)
Jarvis, C. (2014). Physical examination & health assessment. St. Louis, MO: Saunders Elsevier.
Lengkapku, L. P. (2013, August 3). Nursing Interventions and Rationales: Impaired Gas exchange.
Retrieved February 2, 2016, from http://nursinginterventionsrationales.blogspot.ca/2013/08/impaired-gasexchange_3.html
Page, S. L. (2013, November 18). Nursing Care Plan & Ineffective breathing pattern with Nursing
Interventions & Goals. Retrieved February 2, 2016, from http://www.registerednursern.com/nursing-careplan-ineffective-breathing-pattern-with- nursing-interventions-goals/
Sanders. (2012). NURSING DIAGNOSIS: Ineffective breathing pattern.
Retrieved February 2, 2016, from
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?di d=240
Volsko, T. A Airway Clearance Therapy: Finding the Evidence
doi: 10.4187/respcare.02590 Respiratory Care October 1, 2013 vol. 58 no. 10 1669-1678