Impaired gas exchange subjective data

Running head: CONCEPT MAP 1

Copyright ©2018 Capella University. Copy and distribution of this document are prohibited.

Concept Map

Learner’s Name

Capella University

Biopsychosocial Concepts for Advanced Nursing Practice I

Concept Map

April, 2019

CONCEPT MAP 2

Copyright ©2018 Capella University. Copy and distribution of this document are prohibited.

Concept Map

Patient Info

Name: Jane Doe | Gender: Female | Age: 72 Vitals: Temp: 37 °C (98.6 °F), BP: 162/94, Pulse: 92, Respiratory rate: 26 and shallow Chief complaint: Shortness of breath (SOB) and difficulty breathing Medical history: Hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD)

Nursing Diagnosis Impaired gas exchange related to destruction of the alveoli, narrowing of bronchioles, and trapping of air resulting in loss of lung elasticity Subjective data: Difficulty breathing and SOB Objective data: Crackles and wheezing heard upon auscultation, dyspnea, tachypnea, nasal flaring, use of accessory muscles, late signs of cyanosis (Linton, 2015), and oxygen saturation is 90% on room air

Nursing Diagnosis Activity intolerance related to hypoxia (imbalance between oxygen supply and demand)

Subjective data: “I find it difficult to breathe. I can’t catch my breath when I walk a few feet.” — Jane Doe

Objective data: Late signs of cyanosis, crackles and wheezing heard upon auscultation, and use of accessory muscles (Linton, 2015)

Nursing Diagnosis Ineffective airway clearance related to bronchoconstriction, increased mucus production Subjective data: The patient states she has been sleeping in a recliner chair for the past three nights because of difficulty breathing

Objective data: Wheezing heard upon auscultation, dyspnea, tachypnea, and use of accessory muscles (Linton, 2015)

Nursing Interventions

Independent intervention (II): Monitor the patient’s arterial blood gases, oxygen saturation, vital signs, and color and assess for manifestations such as restlessness, anxiety, lethargy, and confusion Rationale: This process will help detect potential hypoxemia or hypercapnia (LeMone et al., 2015)

Collaborative intervention (CI): Supervise oxygen (O2) at 2 L/min through nasal cannula as ordered. Instruct the patient and kin not to increase the O2 level Rationale: Oxygen therapy is used to treat hypoxia and is prescribed for chronic and acute breathing problems (Rees, 2017). However, a sudden increase in the O2 level can lead to respiratory failure (Linton, 2015)

II: Position the patient in an upright or high Fowler’s position (Linton, 2015) Rationale: This posture promotes lung ventilation (LeMone et al., 2015)

II: Instruct and teach the patient to perform the pursed-lip breathing technique Rationale: This technique slows the respiratory rate and reduces air trapping and fatigue (LeMone et al., 2015)

Expected Outcomes Arterial blood gases and vital signs will be consistent with patient norms, indicating improvement in gas exchange (Linton, 2015)

The pursed-lip breathing technique will reduce dyspnea (Linton, 2015)

Nursing Interventions II: Demonstrate pursed-lip and diaphragmatic breathing and encourage the patient to practice them periodically Rationale: These techniques reduce air trapping and fatigue and help maintain open airways (LeMone et al., 2015)

II: Position the patient in an upright or high Fowler’s position Rationale: This posture promotes lung ventilation (LeMone et al., 2015)

CI: Encourage deep breathing and the use of an incentive spirometer Rationale: Using an incentive spirometer prevents complications such as pneumonia and atelectasis (LeMone et al., 2015)

CI: Collaborate with a respiratory therapist to teach the patient how to cough effectively Rationale: This technique helps open distal alveoli and remove secretions (LeMone et al., 2015)

II: Provide emotional support to the patient Rationale: This intervention will be therapeutic, make the patient feel comfortable, and help her cope with the diagnosis (Kazanowski, 2017; LeMone et al., 2015)

Expected Outcomes The patient will have open airways. Signs of clear and open airways are normal depth and rate of respiration, normal breathing sounds, and effective coughing of secretions (Linton, 2015)