Pt goals question

[aerorunner80, ADN, BSN, MSN, APRN]

We had a careplan thrown on us last week at school that we were allowed to work on in our clinical groups together. Our instructor led us through several parts including the pt goal/interventions.

She told us that using the incentive spirometer was a goal when the majority of our group sees using the incentive spirometer as an intervention for the goal of lung expansion.

Another thing that didn't make sense is that she wanted us to use this goal (using the IS) on a person that has pulmonary edema.

I personally think that my first goal would be to reduce the pulmonary edema via collaborative care and then work on lung reexpansion since activity tolerance could possibly be increased. So my interventions after lung fields were cleard would be oob for meals to enhance lung expansion along with incentive spirometry use.

The basis of the pt information on this is that the person was admitted for increasing dyspnea on exertion and orthopnea (started sleeping on 3 pillows). She has coorifice crackles bilaterally mid lung. RR is 28 and shallow. O2 on room air is 86 (ordered: 4L nc-titrate to maintain sat at 90%). Lips and extremities are cyanotic. Bilateral pitting edema 2+ feet to midcalf. CXR shows vascular congestion of lung fields consistent with pulmonary edema.

Related respiratory history is recent respiratory tract infection (does not specify upper or lower or time frame since infection), frequent cough (does not specify productive or not) and bilateral LE edema as stated above. She had an MI 4 years ago and also has a fib. She also has jugular vein distension.

Current meds are furosemide and digoxin which she "does not always remember to take every day"

What do you guys think?

[Daytonite, BSN, RN]

incentive spirometry encourages deep breathing by providing visual feedback while also measuring respiratory flow and volume. it increases lung volume, increases alveolar inflation and actually hyperinflates the alveoli preventing their collapse (thus preventing atelectasis and pneumonia), and promotes venous return. is is of most use for a patient on bed rest who is not able to breathe normally, can cooperate in using the device and can deep breathe effectively.

a goal is the expected result of a nursing intervention that has been ordered and performed by a nurse. for a goal of using the incentive spirometer for a patient who was admitted with pulmonary edema i would have anticipated that independent nursing interventions would have included encouraging this patient to be doing some deep breathing and coughing. pulmonary edema is fluid that has accumulated in the extravascular spaces of the lung and although it is often a complication of heart disorders it can be a chronic condition. these patients often have a persistent cough that may or may not be productive and are dyspneic, often with exertion. because their lungs are so gunked up with secretions they need to get those lungs expanded and those secretions moved up and out. an incentive spirometer would be employed to assist in that if the patient meets the criteria for it (able to breathe normally, can cooperate in using the device and can deep breathe effectively). so, the goal is quite appropriate.

i personally think that my first goal would be to reduce the pulmonary edema via collaborative care and then work on lung reexpansion since activity tolerance could possibly be increased. so my interventions after lung fields were cleared would be oob for meals to enhance lung expansion along with incentive spirometry use.

i'm not being mean here, but it is the doctor's job to order specific treatments for the pulmonary edema. we treat the patient's response to their medical disease. collaborative care means carrying out the physician's orders. there is only one way for secretions to move out of the lungs and that is through the upper airways. if the alveoli aren't cleared out first, then the bronchi, the patient won't be doing much activity until his lung congestion is improved. coughing and deep breathing, as a nursing treatment for this patient is at the top of the list. as nurses we can independently teach and encourage the patient deep breathe and cough. using is if the facility allows this $$ charge to the patient is an acceptable assistive device in accomplishing this.

deep breathing and coughing comes under ineffective airway clearance and it can be a teaching intervention:

• deep breathing
  
  • lie supine with legs slightly bed at the knees; can also be done sitting and standing
    
  • take as deep breath as possible through the nose and allow the abdomen (not the chest) to rise
    
  • hold the breath for a count of five
    
  • exhale completely through pursed lips as if whistling allowing the ribs to sink downward and inward
    
  • rest several seconds and repeat 5 to 10 times every hour
    

  [*]coughing

  • take a slow deep through the nose and expand the chest fully
    
  • breathe out through the mouth feeling the chest sink down and in
    
  • take a second slow breath through the nose expanding the chest fully and breathing out
    
  • take a third breath in the same way but hold it
    
  • the patient should now cough two or three times (once is usually not enough) and concentrate on using the diaphragm to force the air out
    
  • follow with several normal breaths exhaling slowly
    
  • do this every 2 hours
    

priority of care. . .maslow (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). . .oxygenation comes first. you can't get any o2 into the airways until they are cleared of their gunk and the alveoli are opened.

[aerorunner80, ADN, BSN, MSN, APRN]

Thanks!!!!