Need Help! Nursing Care Plan

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Can anyone help me with my first assignment in uni please~

I have a case study given and need to write a nursing care plan.

There is a woman 38yr old and newly arrived immigrant from Lebanon. she is admitted suffering acute asthma exacerbated by an URTI.

she has a poor knowledge about asthma and she did not seek treatment despite feeling unwell.

the signs and symptoms are dyspnoea, hypoxia, alkalosis, hypocarbia, ↑RR, ↑PR,↑temperature, skin feels hot and clammy, coughing, cough productive of thick yellow sputum, tripod position.

she lives close to an industial area and her husband is a heavy smoker.

she's antious and worried.

I'm asked to focuse on the nursing diagnosis of Impaired Gas Exchange.

What are the nursing goals, outcomes and interventions?

could anyone please help me getting any idea to start with

it would be much appriciated!

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Do you have a care plan book? That is a pretty straight forward dx and the books have all of the goals / outcomes listed right there for you. You should think about getting one.

One goal could be Pt's 02 sat will be 95% or greater by ( whatever date you feel appropriate)

But really get a care plan book, you will be so happy!

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I agree, get a good care plan book!! Your life will be so much easier.

Ideally, they want you to be able to come up with appropriate interventions on your own, but as a new student, sometimes it is very hard to get started. A good care plan book will help guide you in the right direction.

For coming up with a goal, I like to think, okay what is wrong with the patient and if it was right, what "evidence" would I see? So for impaired gas exchange, a good marker of this is SpO2 level. So a patient with a "normal" or "good" SpO2 level would be more like 95% or better. So your goal could be SpO2 level of 95% by a certain time.

Then for the interventions, think about what you can do to make your goal happen. What are ways you make you patient breathe easier and better? How about raising the head of the bed? Simple action, but can make a world of difference.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you are the 3rd student in the last 3 days asking about asthma and impaired gas exchange. must be something in the air! you should read the information on these threads about impaired gas exchange because most of the signs and symptoms are listed on the first couple of threads i listed:

nursing goals/outcomes and interventions are based upon the specific symptoms of asthma that you find and decide to use for this care plan. not all of the symptoms listed in your case scenario are defining characteristics (symptoms) of impaired gas exchange. impaired gas exchange is a commonly used nursing diagnosis for patients who have respiratory problems where the exchange of oxygen and carbon dioxide at the alveolar/capillary walls is somehow being impeded. this included such conditions as asthma, pneumonia and the various forms of copd, so you will be using it a lot. it is important you understand what this diagnosis is about and what the defining characteristics (symptoms) of this diagnosis are. here are links to webpages that have the official nanda information on them plus some nursing interventions. [color=#3366ff]impaired gas exchange and http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=23

for more on how to write care plans see the sticky thread:

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Thanks to all for helping me out.

but still don't get it..:cry:

I think I really need to get a care plan book!!

would you please recommend a good one? if you have

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Specializes in med/surg, telemetry, IV therapy, mgmt.
thanks to all for helping me out.

but still don't get it...i think i really need to get a care plan book!!

would you please recommend a good one? if you have

i'm not letting you get off that easy. a care plan book is only going to plug the hole in the dam, but not correct the problem so it doesn't occur again. you will have other care plans to write and the same problem will present itself, so let's tackle it now.

what is it that you are not getting?

is this a group project? are you only supposed to focus on nursing goals, outcomes and interventions? you have to know the patient's symptoms of her asthma and urti that she is exhibiting before you can even begin to start focusing on nursing goals, outcomes and interventions. why? because these things are all based upon and linked to each other. goals and outcomes are the predicted results you expect will happen when you perform nursing interventions. nursing interventions are aimed at the symptoms the patient has, or else why would you be doing them?

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I had looked at the threads that you've linked for me

and I gained a little bit of understanding about the signs & symptoms of Impaired Gas Exchange. so thanx again

however, still got some questions

you know how Mrs Fatmah has a higher level of temperature than normal, is this related to the infection? what causes high temperature?

if you could help me with this, these are the questions of the assignment:

1. write a nursing diagnosis statement

2. why impaired gas exchange occurs in asthma

3. why the signs and symptoms occur when gas exchange is impaired

4. state appropriate goals of nursing care relevant to the problem of impaired gas exchange

5. identify priorities i.e. explain what goal's should be met first and why

6. state expected outcomes that the nurse will use to evaluate if the nursing care given to Fatnah is improving her gas exchage

7. write nursing actions to achieve the goal/s of care

8. write a rationale for each nursing action i.e. explain how the action will achieve the goal/s of care

As I said before, I'm asked to focus on Impaired Gas Exchange.

but, does that mean that im not able to state goals of nursing care of the other nursing diagnosis rather than IGE? such as Ineffective airway clearance and Ineffective breathing pattern.

you know how it's all related to each other isn't it?

I asked my lecturer this question, but she didn't give me a clear answer to that..so..

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you know how mrs fatmah has a higher level of temperature than normal, is this related to the infection? what causes high temperature?

this is a question about basic nursing, not care planning. the answer should be in a fundamentals of nursing textbook, a book of anatomy/physiology or pathophysiology.

yes, fever is related to infection. fever is one of the symptoms of infection.

(page 171,
differential diagnosis in primary care
, 4th edition, by r. douglas collins) "increased heat in the body is caused by increased production or decreased elimination or dysfunction of the thermoregulatory system in the brain. increased production of heat occurs in conditions with increased metabolic rate such as hyper thyroidism, pheochromocytomas, and malignant neoplasms. poor elimination of heat may occur in congestive heart failure (chf) (poor circulation through the skin) and conditions where sweat glands are absent (congenital) or poorly functioning (heat stroke).
most cases of fever are caused by the effect of toxins on the thermoregulatory centers in the brain
.
these toxins may be exogenous from
drugs,
bacteria (endotoxins)
, parasites, fungi, rickettsiae, and virus particles, or they may be endogenous from tissue injury (trauma) and breakdown (carcinomas, leukemia, infarctions and autoimmune disease)." i red bolded the parts that apply to your patient.

the hypothalamus of the body regulates body temperature. a fever is an elevation of the hypothalmic set point. this is caused by

  • central nervous system disease

  • malignant hyperthermia

  • strenuous exercise

  • stress

  • chills (produce more heat and, thus, raise the body temperature)

  • thyrotoxicosis

  • heatstroke

  • heart failure

  • congenital absence of sweat glands (sweating helps the body get rid of heat)

  • drugs that impair sweating

if you could help me with this, these are the questions of the assignment:

1. write a nursing diagnosis statement

a nursing diagnosis statement for
impaired gas exchange
was given in the posts i listed for you above. yours will be much the same except it will include as evidence (symptoms) the signs and symptoms that apply:
impaired gas exchange related to ventilation perfusion imbalance secondary to asthma and urti as evidenced by dyspnea, hypoxia, hypocarbia, ↑rr, and ↑pr.

2. why impaired gas exchange occurs in asthma

that was also explained in the posts i listed in my first reply to this thread. the pathophysiology of asthma explains this:

(from
pathophysiology: a 2-in-1 reference for nurses
by springhouse, springhouse publishing company staff, pages 244-249)

"in asthma, hyperresponsiveness of the airways and bronchospasms occur.

  • histamine attaches to receptor sites in larger bronchi, causing swelling of the smooth muscles

  • leukotrienes attach to receptor sites in the smaller bronchi and cause swelling of smooth muscle there. leukotrienes also cause prostaglandins to travel through the bloodstream to the lungs, where they enhance histamine's effects

  • histamine stimulates the mucus membranes to secrete excessive mucus, further narrowing the bronchial lumen. on inhalation, the narrowed bronchial lumen can still expand slightly; however, on exhalation, the increased intrathoracic pressure closes the bronchial lumen completely.

  • mucus fills lung bases, inhibiting alveolar ventilation. blood is shunted to alveoli in other parts of the lungs, but it still cant compensate for diminished ventilation.

wheeze during coughing occurs. air enters the lung, but can't escape. hyperventilation is triggered by lung receptors to increase lung volume because of trapped air and obstructions. mucus fills the lung bases. intrapleural and alveolar gas pressure rises, causing a decreased perfusion of alveoli. increased alveolar gas pressure, decreased ventilation, and decreased perfusion result in uneven ventilation-perfusion ratios and mismatching [disruption in the balance of oxygen and carbon dioxide that are normally exchanged at the alveolar level] within different lung segments.

hypoxia triggers hyperventilation by respiratory center stimulation, which in turn decreases partial pressure of arterial carbon dioxide (paco2) and increases ph, resulting in respiratory alkalosis. as the airway obstruction increases in severity, more alveoli are affected. ventilation and perfusion remain inadequate, and carbon dioxide retention develops. respiratory acidosis results, and respiratory failure occurs.

if status asthmaticus occurs, hypoxia worsens and expiratory flows and volumes decrease even further. if treatment isn't initiated, the patient begins to tire out.

acidosis develops as paco2 increases. the situation becomes life-threatening as no air becomes audible upon auscultation and paco2 rises to over 70 mmhg."

3. why the signs and symptoms occur when gas exchange is impaired

this was also in that same post:

  • dyspnea [increased alveolar gas pressure, decreased ventilation, and decreased perfusion resulting in uneven ventilation-perfusion ratios and mismatching - for the nursing diagnosis of
    impaired gas exchange
    the related factor this is referring to is "ventilation perfusion imbalance".]

  • wheezing [narrowed bronchial lumens]

  • tightness in the chest [the pressure of built up and trapped gasses that can't get out]

  • productive cough of thick clear or yellow sputum [excessive mucus secretion due to release of histamine]

  • tachypnea [lung receptors triggered in an effort to try to increase lung volume due to trapped air and obstructions]

  • rapid pulse [the heart's attempt to deliver more oxygen to the tissues of the body]

  • hyperresonant lung fields [build up of air and co2 that is trapped in the lungs and can't get out]

  • diminished breath sounds [mucus fills many of the alveoli as a result of the inflammation response; because of bronchospasm the patient has difficulty coughing the secretions up and out]

4. state appropriate goals of nursing care relevant to the problem of impaired gas exchange

what are your interventions for the dyspnea, hypoxia, hypocarbia, elevated rr, and tachycardia? goals are based upon what your interventions are aimed at fixing. if you are giving oxygen to help improve the ventilation perfusion imbalance (equalize the balance of oxygen/carbon dioxide gas being exchanged at the alveolar-capillary membrane) then that is the goal of those interventions with oxygen. you might write it differently, i.e.
by discharge patient will have arterial blood gas levels within normal parameters
.

5. identify priorities i.e. explain what goal's should be met first and why

back to that other post again (
https://allnurses.com/forums/f205/help-my-nursing-care-plan-assignment-related-asthma-gas-exchange-303903.html
)

the priority of treatment depends on where the disease process has come to. if the patient is at the stage of
acidosis develops as paco2 increases. the situation becomes life-threatening as no air becomes audible upon auscultation and paco2 rises to over 70 mmhg
then treatment is going to involve doing something immediately about the zero lung sounds and paco2 of 70--this patient is going to be intubated, an iv started and the acidosis corrected. this is why assessment of the patient is of primary importance in the nursing process.

in other words, when working on a case scenario, you look at the progressive symptoms and the treatment for them and work backwards to get the order of priority. however, in general you do follow the abcs giving consideration to the order of oxygenation requirements of the various tissues (brain, heart, then lung)

    • a
      - establish airway and oxygenate
      • give medications as ordered
        • mast cell stabilizers - halt/slow down the inflammation reaction

        • antihistamines - halt/slow down the inflammation reaction

        • bronchodilators - open the bronchial lumen

        [*]perform treatments as ordered

        [*]administer oxygen - maximize % of oxygen perfused during alveolar gas exchange

      [*]
      b
      - breathing

      • get patient in high fowler's position - reduces pressure on the diaphragm and lung

      • show the patient how to perform pursed lip breathing - lengthened expiratory breathing time helps blow off more co2

have equipment ready for emergency intubation and suction - saves time

6. state expected outcomes that the nurse will use to evaluate if the nursing care given to fatnah is improving her gas exchange

this depends on how your nursing program defines "outcomes". to me, outcomes and goals have a different meaning from what your instructions may have defined them for you.

7. write nursing actions to achieve the goal/s of care

this is nothing more than nursing interventions. nursing interventions are always written to address the evidence (symptoms, defining characteristics) that support why you have determined a specific nursing problem--in this case,
impaired gas exchange
. so, you will write nursing interventions for

  • dyspnea

  • hypoxia

  • hypocarbia

  • ↑rr

  • ↑pr (tachycardia)

nursing interventions come in 4 general types:

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)

  • care/perform/provide/assist (performing actual patient care)

  • teach/educate/instruct/supervise (educating patient or caregiver)

  • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

this is just an example of some of the interventions i would write. these are from my experience. you should be able to find more in your textbooks:

  • assess patency of airway and verify that the patient has an open airway by noting that patient is moving air in and out of lungs

  • administer oxygen
    • perform a safety check of the room

    • place an oxygen precaution sign over the patient's bed and on the door to the patient's room

    • place the nasal cannula on the patient so that it is fitting comfortably

    • check the patient's response to the oxygen by monitoring pulse oximetry readings

    • observe for signs of hypoxia

    • observe nostrils and back of ears for skin breakdown

    [*]assess and document respiratory rate, rhythm and depth along with breath sounds at least q4h

    [*]notify physician of abnormal abgs or symptoms of increased dyspnea

8. write a rationale for each nursing action i.e. explain how the action will achieve the goal/s of care

this is something you have to do by finding your nursing interventions in a nursing textbook or other resource such as a care plan book and then referencing it when you write the nursing intervention on your care plan. i've always said that a care plan in college is very much like doing a term paper for an english class. well, here you go. this is why you had to take english composition.

as i said before, i'm asked to focus on impaired gas exchange.

but, does that mean that im not able to state goals of nursing care of the other nursing diagnosis rather than ige? such as ineffective airway clearance and ineffective breathing pattern.

you know how it's all related to each other isn't it?

i don't know. read the instructions carefully. if you were asked to focus on ige, what would be the point of deviating and including information about other diagnoses? your grade might suffer for it. the one thing i noticed about the symptoms in the scenario is that not all of them pertained to ige. maybe that was part of the point of the exercise, you think? perhaps your instructor(s) are looking to see who is "getting" how nursing diagnosis works and not who does the most work.

i asked my lecturer this question, but she didn't give me a clear answer to that..so..ask her again, or read the written instructions over and over until they are clear in your mind. if the instructions are in writing, then there is no confusion about what to do. are you sure you didn't have lectures or handouts on nursing diagnosis? because you generally won't find all this information about choosing and working with specific nursing diagnoses in any books. it's passed down in lectures.

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