So a little background on my patient. He came in through the E.D. SOB, 3L NC O2 as 90% they gave him a breathing treatment his O2 went to 100%. He has a history of COPD and has been intubated several times in the passed. He was put on Bipap but his LOC decreased and they decided to intubate. When I had him he was in the ICU, intubated, ABGs were all out of whack, as to be expected. His O2 sat was running from 93-100 he still has wheezes and decreased breath sounds. Many of the Nursing diagnosis that I have found are for COPD patients that are not currently on mechanical ventilation. Right now I am trying to figure out 3 top diagnosis and then prioritizing them. I have- Ineffective airway clearance r/t expiratory airflow obstruction, bronchoconstriction AEB wheezing, difficulty breathing, impaired gas exchange r/t ventilation perfusion inequality AEB abnormal ABG values, reduced tolerance for activity, risk for infection: risk factors: inadequate primary defenses, chronic disease process, malnutrition. He had a chest x-ray and there was no pneumonia just overinflation and presence of chronic lung disease. Do you guys have any advice on better nursing diagnosis/ better prioritization?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Yeah, that makes sense. His skin was fine, no breakdown. He had just been admitted the evening before. He was in end-stage COPD so I could go towards powerlessness r/t progressive nature of disease? I feel like my prof. would say he wouldn't be at risk for infection because we were performing peri care Q8H. Thanks for your help, I appreciate it!
any invasive line is cause for opportunistic infection...regardless how much you wash the peri area as are the IV lines and ETT tube.
cmarcus
14 Posts
He was on solumedrol.
Thank you!