Arthur Thomason, 56-year-old MVA victim, fourth day post op with a splenectomy and femur repair. He is experiencing new onset of shortness of breath and has a nasal cannula with 2L of Oxygen in place. He is restless with slight confusion but is easily orientated with attempts from nurse. Temperature spiked during the night to 102.4, BP now 146/94 which is slightly elevated, respirations at 30 bpm and slightly labored, heart rate 102 versus 84 from last night shift. Skin cool to touch and appears pale. His coughing, to clear his airway, appears ineffective. Recent chest X-ray shows diffuse bilateral interstitial infiltrates in all lobes. Recent blood gases demonstrate falling PaO2 (hypoxemia) and increasing CO2 (Hypercapnia). Mr. Thomason is anxious and is obviously worsened from the shift before in overall condition. Required:
Write a Nursing plan. Write a Nursing Care Plan Assessment, Diagnosis, Goal, Implement, Evaluation

Solution :

Nursing the care plan

Assessment

To assess the respiratory rate, the depth, the abnormal breathing pattern.

Monitor the behavior of the patient and the mental status for the onset of the restlessness and confusion.

Observe for the nail beds and the cyanosis in the skin.

Monitor the oxygen saturation continuously with the help of a pulse oximeter.

Nursing diagnosis

Impaired the gas impaired exchanged related to the airway obstruction as a evidence by the restless and shortness of the breathing and confusion.

Goals

Improving the gas exchange and also improve the breathing pattern.

Intervention

Position the patient with his or her head elevated from the bed in a semi Flower's position.

Evaluation

The patient can breathe normally and then reduce the restlessness and the confusions.

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