Impaired Gas Exchange with no condition to relate it to?

Lev, MSN, RN, NP · Apr 17, 2016

Was she on narcotics for pain from the cellulitis that made her respirations more shallow/slower?

Does she have a history of smoking/copd or sleep apnea?

Jenwith1N · Apr 17, 2016

Was she on narcotics for pain from the cellulitis that made her respirations more shallow/slower?
Does she have a history of smoking/copd or sleep apnea?

She has Hydromorphone on her PRN orders but had not been given any on the day I was with her. The depth of her respiration seemed sufficient and the rate was within normal limits (14).

There was nothing in her documented history (HTN, diabetes, arthritis, thrombocytepenia, anemia, breast cancer, and no history of smoking). Her daughter mentioned that she needed to get a new prescription for a "mask to wear at night" (they both were native Spanish speakers, my patient spoke no English) but had not seen that doctor yet. I don't think I can use that since it wasn't verified. My professor is really strict about us having proof.

My other problem with the possible sleep apnea is that her O2 sat was low while she was awake as well.

Another student in my class was assigned to the same patient the next day. She was still on O2 while she was working with her. She might have developed a new condition but I have nothing in my information for it.

la_chica_suerte85, BSN, RN · Apr 17, 2016

Were her hands cold? What was her cap refill like? Has she had a mastectomy? Where was the cellulitis/lymphedema? Did you try other areas with the pulseox (e.g. if she had a mastectomy, it might not be the best idea to have the pulse ox on the digit of the limb that the mastectomy occurred on)? Finally, was her Hx of anemia d/t chemo treatment for breast cancer?

A related to actually has to be related to the symptom. She has impaired gas exchange for some reason (maybe) but saying "related to drop in O2 sats" is not proof (it would be an "as evidenced by" for sure, but a "related to" not so much). An example of a diagnosis with impaired gas exchange would be "Impaired gas exchange r/t damage to capillary membrane" or "Impaired gas exchange r/t decreased lung compliance." So, your r/t needs to be some physical reason, a pathophysiological cause of the problem. For this pt, maybe her hgb was low? So, a diagnosis would go "Impaired gas exchange r/t insufficient oxygenation as a result of low hemoglobin levels AEB a decrease in O2 saturation from a baseline of 99% to 88%." (it's janky but I don't know the situation myself and can't see the Hx so I'm just taking a stab in the dark).

I hope this helps.

Jenwith1N · Apr 18, 2016

The information I posted in my original post is everything I have. Her chart was pretty thin. She was admitted the day before my shift with her.

I think I remember noting that her skin was warm (I have to turn in my assessment sheet at the end of the night and don't have it noted in my personal notes). She was chilly herself though. She needed two blankets to get comfortable.

She did not have a mastectomy but she had a "save this limb" band on the side she had the cancer on. I used my pulse ox on 2 different fingers on the opposite hand. The cellulitis and lymphedema were in both of her legs. She had 4 ulcers on her right leg and weeping in both. I'm not sure about her anemia. It wasn't even listed in her chart (digital or paper). I found out about the anemia in my nightly report at shift change.

RBC, Hgb, Hct, and lymphocytes were low. Glucose, monocytes and eosinophils were high.

Impaired gas exchange r/t insufficient oxygenation as a result of low hemoglobin levels AEB a decrease in O2 saturation from a baseline of 99% to 88%.

I LOVE this! I don't think anyone else in our group has thought to use our patient's lab results to help with a diagnosis. I didn't. I'll keep in mind for future cases too. Thank you!