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CUES Subjective Cues: No verbatim V2Incomprehensi ble sounds.

Objective Cues: *restless *dyspnea *coarse crackles heard upin auscultation of both lung fields (more prominent on right lung field) *RR=30 breaths/minut e with use of accesory muscles *shallow inhalation and shallow expiration Laboratory Results: ABG

DIAGNOSIS Impaired gas exchange related to pulmonary edema

RATIONALE Alcoholic cirrhosis leads to portal hypertension. This would lead to inability of the circulating blood to pass through the liver. Since there is a buildup of circulating blood, there will inadequate ventricular function in the left side of the heart leading to left sided heart failure.

OUTCOME

INTERVENTIONS 1. Assess vital signs Note cardiac rhythm, respiratory rate and depth and work of breathing (such as use of accessory muscles or nasal flaring and pursed-lip breathing) Report vital sign changes.

RATIONALE 1. Tachypnea and dyspnea accompany pulmonary obstruction. Dyspnea and increased work of breathing may be first or only sign of subacute PE. Severe respiratory distress and failure accompanies moderate to severe loss of functional lung units.

INDICATORS 1-3 a. identifies the health needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of equipments g. fulfills legal requirements in nursing practice h. accomplishes accurate documentation in all matters concerning patient care in accordance to the standards of nursing practice i. detects variation in the vital signs of the patient from day to day j. shares with team current information regarding particular patient condition k.performs daily check patients condition l. completes updated

1. The patient will be able to demonstrate adequate ventilation and oxygenation as evidenced by patients ABG in normal range after 72 hours of nursing care. 2. The patient will display resolution or absence of symptoms of respiratory distress as evidenced by RR=12-20 breaths/minute, An inadequate which is normal in left ventricular rate and rhythm function in Heart and capillary refill Failure, causes time of less than an increased 2 seconds after microvascular 72 hours of pressure from nursing care. abnormal cardiac function causing the blood to back up into the pulmonary vasculature and

2. Assess level of consciousness and evaluate mentation changes.

2. Systemic hypoxemia may be demonstrated initially by restlessness and irritability, then by progressively decreased mentation

3. Assess activity tolerance, such as reports of weakness and 3. Nonventilated fatigue, vital sign areas may be changes, or identified by

Respiratory Acidosis pH= 7.29 HCO3= 20 PaCO2= 55 PaO2 = 88

Chest X-ray
Densities produced by fluid,

as fluid begins to leak into the interstitial space and the alveoli it leads to a deficit in oxygenation and carbon dioxide elimination at the alveolicapillary membrane.

increased dyspnea during exertion. Auscultate lungs for areas of decreased and absent breath sounds and the presence of adventitious sounds, such as crackles. 4. Institute measures to restore or maintain patent airways, suctioning.

absence of breath sounds. Crackles occur in fluid filled tissues and airways or may reflect cardiac decompensation.

documentation of patient care

4. Plugged or collapsed airways reduce number of functional alveoli, negatively affecting a. identifies the health gas exchange. needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques 5. Elevate head of f. checks proper bed as client Promotes maximal functioning of tolerates. chest expansion, equipments making it easier to breathe and a. identifies the health enhancing needs of the patient physiological and b. identifies the problem psychological c, gathers data related

a. identifies the health needs of the patient b. identifies the problem c, gathers data related to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of equipments

comfort.

6. Assist with frequent changes of position.

Turning enhances aeration of different lung segments, thereby improving oxygen diffusion.

to the problem d. monitors the progress of the action taken e. performs appropriate assessment techniques f. checks proper functioning of equipments

7-13 a) Identifies the health needs of the Collaborative patients 7. Prepare for lung b) gathers data scan. May reveal pattern related to problem 8. Monitor serial of abnormal analyzes the data ABGs or pulse perfusion in areas of c) gathered oximetry. ventilation, d) perform agereflecting specific safety and ventilation and perfusion mismatch, comfort measures in all aspect of patient care confirming performs diagnosis of PE and e) appropriate assessment degree of techniques obstruction. f) implements Absence of both nursing intervention ventilation and that is safe and perfusion reflects comfortable 9. Administer alveolar

supplemental oxygen by appropriate method.

g) checks proper functioning of equipments Hypoxemia is h) demonstrate present in varying knowledge of method degrees, depending appropriate for the on the amount of clinical problem airway obstruction, identified usual i) participates cardiopulmonary actively in the care function, and management including presence and audit 11.Provide degree of shock. j) respect roles of supplemental Respiratory alkalosis other members of humidification, and metabolic health team such as ultrasonic acidosis may also k) refer patients to nebulizers. be present. allied health team partners Maximizes available act as liaison for oxygen for gas patients exchange, reducing work of breathing. Note: If obstruction is large or hypoxemia does not respond to supplemental 12.Assist with oxygenation, it may chest be necessary to physiotherapy, move client to such as postural critical care area for drainage and intubation and percussion of mechanical nonaffected area, ventilation. blow bottles, and

congestionn or airway obstruction.

incentive spirometer. Facilitates deeper respiratory effort and promotes drainage of secretions from lung 13.Prepare for and segments into assist with bronchi, where they bronchoscopy. may more readily be removed by coughing or suctioning. 14. Administer medications as ordered. Diuretics (Thiazide May be done to diuretics) remove blood clots and clear airways.

Digitalis preparation

*identifies the health needs of the patients *gathers data related to problem analyzes the data gathered *perform age-specific safety and comfort measures in all aspect of patient care *conforms to the 10 golden rules in administration and health therapeutics *performs appropriate - medications used assessment techniques to increase the rate *implements nursing of intervention that is safe urine production and comfortable and the removal of *participates actively in excess extracellular the care management fluid from including audit the body. *respect roles of other members of health - The medication team increases the force refer patients to allied of myocardial health team partners

contraction and *act as liaison for slows conduction patients through the AV node. It improves contractility, increasing left ventricular output. The medication also enhances diuresis, which removes fluid and relieves edema.