Patient Profile Z.Q., 74-year-old Hispanic man, came to the emergency department (ED) 7 days ago with shortness of breath. His wife stated that he had a history of hypertension, depression, and chronic obstructive pulmonary disease (COPD). The admission chest x-ray examination revealed dense consolidation of the left lower lobe. An arterial blood gas (ABG) at that time showed: pH 7.60, PaCO₂ 29mm/Hg, HC0₃ 32mmol/L, and PaO₂ 75mm/Hg. Z.Q. quickly deteriorated and subsequently was intubated. He has been in the intensive care unit for 3 days. Subjective Data Z.Q. and wife have been married 45 years and live with a daughter and two grandchildren. They speak both English and Spanish. Objective Data Physical Examination Blood pressure 167/98, pulse 112, temperature 102.0°F, respirations 14, oxygen saturation 72% Height 5'6", weight 75 kg Patient localizes to endotracheal (ET) tube and is intermittently aroused, making several attempts to pull ET tube Orally intubated #7.5 ET tube, taped at 27 cm to lip Volume cycled ventilator at FIO₂ - 60%, in assist control mode of 14 breaths per minute, tidal volume 450, positive end-expiratory pressure PEEP 5 cm H2O Breath sounds decreased in bases with bilateral crackles that do not clear after suctioning Brown-yellow secretions returned with suctioning Peripheral pulses weak at 1/4 with capillary refill greater than 4 seconds 2+ pitting edema in the bilateral lower extremities Newly Obtained Diagnostic Study Results Arterial blood gas (ABG) pH 7.31, PaCO₂ 58mm/Hg, HCO₃ 28mmol/L, PaO₂ 54mm/Hg, EtCO₂ 38 mm/Hg Chest x-ray examination reveals diffuse white out in middle and lower lobes; endotracheal tube present with tip well above the carina; left subclavian central venous catheter is in the superior vena cava Computed tomography scan reveals alveolar opacities with increasing effusions in the gravity-dependent areas of the lungs
How would you as the nurse, evaluate the effectiveness of your nursing interventions for Z.Q.
What 5 prioritized nursing interventions will be initiated by you as the nurse based on your listed initial nursing priority.
Q.5 What 5 prioritized nursing interventions will be initiated by you as the nurse based on your listed initial nursing priority.
The five priority nursing interventions in this patient will be aimed at maintaining his Airway, breathing and circulation. Since the patient is on mechanical ventilation and having poor oxygenation, the goal of these priority interventions will be to improve his oxygenation status and prevent the worsening of the respiratory failure.The five prioritized nursing interventions that will be initiated by the nurse(by me) based on the listed initial nursing priorities are tabulated below
|Prioritized nursing interventions||Rationale for nursing interventions|
1a).Maintenance of the airways by intermittent aseptic suctioning of the endotracheal tube:
1.b )Sending the secretions for culture and seeking physician advice for change in the antibiotic therapy.
1a).Patient is having profuse brownish yellow secretions and poor oxygenation. The presence of these secretions will block the airway and worsen oxygenation status. So nursing intervention will be to intermittently suck the secretions and maintain the airway patency.
1b)Providing antibiotics as per the culture will help to resolve the lung infection and decrease the secretions
2.Monitoring the ventilatory settings and alarms regularly and seeking help of respiratory therapist to assess for altering the settings in view of decrease in the PO2 from 75 to 58 mmHg to maintain effective breathing.
2T.he patient has had a decrease in the oxygenation.PO2 has decreased from 75mmHg to 58 mmHg on mechanical ventilation and so the nurse must monitor the ventilator settings and seek help from the respiratory physician/therapist as to if there is a need of alteration and also reset the alarm if required
|3.To maintain patient breathing and mechanical ventilation,the nurse must place soft wrist restraints for the patient.||
3.The patient gets aroused intermittently and attempts to remove the endotracheal tube.The patient may go into sudden respiratory distress on his forceful pulling out of the endotracheal tube. To prevent this from happening ,the nurse must place soft wrist restraints on the patient's wrists after explaining the procedure to the patient/patient's attenders and obtaining the proper consent from him/his attenders
|4.Maintain optimum blood circulation and patient hydration by IV fluid infusion as directed by the physician.||4.The patient must have an effective circulation in order to improve his oxygenation. Adequate hydration is required in order to decrease the consistency of the thick secretions present in the airways,decrease their viscosity and facilitate their expulsion.|
|5.Regular assessment for the improvement in the lung function by lung auscultation and ABG monitoring and watching for signs of barotrauma.[ decrease chest excursions, subcutaneous emphysema ,crepitus pneumothorax on X Ray]||
5.In order to assess for the improvement in the respiratory failure, regular auscultation of the lungs must be done along with P02 and ABG monitoring. Due to the use of PEEP in the mechanical ventilator settings,barotrauma can occur and hence the nurse must monitor the patient carefully for barotrauma as this can further worsen the respiratory failure.
QHow would you as the nurse, evaluate the effectiveness of your nursing interventions for Z.Q.?
In order to evaluate the effectiveness of the nursing interventions,the nurse must assess for the patient's improvement in oxygenation and breathing status both subjectively and objectively based on the nursing goals /outcomes as per the nursing care plan.
The evaluation of the effectiveness of the nursing interventions for Mr ZQ can be done by the nurse (by me) by the following methods
1.Monitoring of the patient's oxygenation status : The effectiveness of the nursing interventions will be evaluated by the improvement in the oxygenation, the increase in PO2 pressure and normal ABG .An oxygen saturation of 95- 100 mmHg would indicate adequate oxygenation of the lungs and provide cue as to weaning the patient of the ventilator.
2,By auscultating the patient's lungs to see for decrease in the foreign breath sounds and improved hearing of the normal breath sounds.The presence of normal breath sounds on auscultation with absence of crackles all over the lung field would indicate patient recovery.
3.By assessing for the decrease in the secretions from the airway while suctioning.The decrease in the secretions quantity and color change from brownish yellow to clear will indicate the effectiveness of the nursing interventions.
4. The patient comfortably placed on to the endotracheal tube and ventilator without trying to remove the tube intermittently indicates adequate restraint effectiveness for facilitating ventilatory breathing.
5.Performance of an X-ray chest to see for the clearing of the lung field, decrease or absence of the opacities.Observation of the normal lung shadow on X-ray denotes resolution of the lung pathology/infection and nursing interventions' effectiveness.
summary:The clearing of the lung infection,weaning of the patient off the ventilator and his maintaining normal oxygenation on his own breathing efforts with normal x-ray are the final evaluatory parameters[outcomes/goals] which will demonstrate the effectiveness of the nursing interventions.
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