i have always told students that nursing has given us one of the greatest tools to help us with our work, but i guess some instructors don't make it clear. i'm talking about the nursing process. the nursing process is a souped up label that was put on the scientific problem solving method
after nurses tweaked it a bit and took ownership of it. when the steps of the nursing process are applied to all kinds of nursing dilemmas, care plans and case scenarios included, it is a huge help. the trick is to follow the steps of the process in the sequence that they occur to get the most out of it. these are the steps and what goes on in each of them for care planning a case scenario situations:
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
scientific problem solving is not a foreign concept to any of us.
we have been doing a form of it for much of our lives. let me give you a real world situation a show you how it also ties in with nursing:
you are driving along and suddenly you hear a bang, you start having trouble controlling your car's direction and it's hard to keep your hands on the steering wheel. you pull over to the side of the road. "what's wrong?" you're thinking. you look over the dashboard and none of the warning lights are blinking. you decide to get out of the car and take a look at the outside of the vehicle. you start walking around it. then, you see it. a huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. what you have just done is step #1 of the nursing process--performed an assessment. you determine that you have a flat tire. you have just done step #2 of the nursing process--made a diagnosis. the little squirrel starts running like crazy in the wheel up in your brain. "what do i do?" you are thinking. you could call aaa. no, you can save the money and do it yourself. you can replace the tire by changing out the flat one with the spare in the trunk. good thing you took that class in how to do simple maintenance and repairs on a car! you have just done step #3 of the nursing process--planning (developed a goal and intervention). you get the jack and spare tire out of the trunk, roll up your sleeves and get to work. you have just done step #4 of the nursing process--implementation of the plan. after the new tire is installed you put the flat one in the trunk along with the jack, dust yourself off, take a long drink of that bottle of water you had with you and prepare to drive off. you begin slowly to test the feel as you drive. good. everything seems fine. the spare tire seems to be ok and off you go and on your way. you have just done step #5 of the nursing process--evaluation (determined if your goal was met).you can't even begin to determine what a patient's nursing problems are until you've done a thorough assessment. that, for us nurses, includes
with hypothetical patients you have to tweak that list a bit since you can't do an actual physical exam (but you can put together a text book list of abnormal findings you would expect to see for the medical diagnoses you have been given), you can't do an actual assessment of the patient's ability to perform their adls (but you can extrapolate that information from what you find out about the medical disease symptoms), and there is no medical chart to gather information from. however, one of the major expectations of doing case studies is that students learn about the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this information is critical (as in critical thinking) in the care planning process, particularly in the determination of nursing diagnoses and their etiological factors. the first two questions from your case study are based in the pathophysiology of asthma. they will also give you the related factor (etiology or cause) for the "r/t" part of the diagnostic statement as well as give you an understanding of how the manifestations of the disease (symptoms) can be directly traced to the pathophysiological happenings. once you learn what the cause and symptoms of asthma are you can then identify priorities and goals of nursing care. your goals will be to improve, stabilize or support the deterioration of each nursing problem you are addressing. nursing care (interventions) of each nursing problem is based upon treating those symptoms. all of this stuff is very rationally interrelated in care planning and fits together like a key fits into a lock. explain why impaired gas exchange occurs in asthma ie: identify the pathophysiological processes that occur in asthma and explain how these processes impair gas exchange.
- a physical assessment of the patient
- assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
- data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
- knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
why the signs and symptoms occur when gas exchange is impaired
(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.
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." here is the pathophysiology of the inflammatory response which you need to know for this case study: http://allnurses.com/forums/f50/hist...ct-244836.html
- 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.
identify priorities ie: explain what goals of nursing care should be met first and why
it is explained in the pathophysiology above. the signs and symptoms of any disease come about as the pathophysiology process continues on untreated.
the signs and symptoms are:
- 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]
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
why all this information becomes important. . .it helps you understand and define the nursing problem. the definition of impaired gas exchange
is excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
(page 94, nanda-i nursing diagnoses: definitions & classification 2007-2008
). the specific problem with asthma is that oxygen and carbon dioxide are not being exchanged across the alveoli membranes because of (1) oxygenated air being blocked from getting to the alveoli because of bronchospasms, and (2) the build up of excess mucus in the alveoli. what is causing the problem in impaired gas exchange
, the nursing diagnosis, is that gas exchange between oxygen and carbon dioxide is not being able to occur as it is supposed to in the alveoli
. so for asthma, using that particular nursing diagnosis is a marriage made in heaven. of course, there are other nursing diagnoses that apply here as well, but you are focusing on this one.
- impaired gas exchange related to ventilation perfusion balance as evidenced by dyspnea, diaphoresis, hypercarbia and tachycardia.
hope i explained that clearly enough and that helps you out. keep this information because it is also relevant for pneumonia and you will have lots of patients with pneumonia! this stuff is not always easy to understand at the first or second reading. you need to get a pathophysiology book to help you with these kinds of assignments. you need to know the pathophysiology of all medical diseases anyway, so it would be a good investment to make.