Respiratory Nursing Diagnoses & Interventions

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Impaired Gas Exhange Ineffective Breathing Pattern
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Oxygenate/Ventilate 1. Mechanical ventilation – std tx with ARDS patients 2. Lowest FiO2 to maintain PaO2 > 60 mmHg – anything more than 50 for 24 hrs –> oxygen toxicity 3. TV < 10 mL/kg (~6 mL/kg) – N+ 4-6 mL PEEP – recruits albeoli & prevents further atelectasis; increases functional residual capacity to allow for continuous gas exchange (complications – pneumothorax, decreased venous return)
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Ineffective Airway Clearance
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Suction PRN using proper technique No matter how much you suction this patient, you can’t get it all out. Standard is based on patient assessment – PRN. Don’t suction too often otherwise you may suction out too much oxygen.
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Alteration in Comfort
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Sedatives – Versed (most comfortable) Analgesics – Morphine Sulfate (MSO4) – peripheral vasodilator – good for HF/edema patients – can cause hallucinations and vomiting Paralytics – Norcuran/Pavulon (may increase pulse and BP, may cause RESPIRATORY DEPRESSION) Always sedate before paralyzing!
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Activity Intolerance/Immobility
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Bedrest Frequent position changes – back to side repositioning can desat a patient Prone position – improves oxygenation; adverse effects – decrease SpO2, facial edema, extubation, delay in CPR, peripheral nerve damage, skin breakdown (used as last resort)
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Altered Nutrition: < BR
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Calorie requirement 1.5 – 2 X normal – due to severe stress state which increases metabolic state Enteral nutrition – aspiration precautions (HOB 30 – 45 degrees; residual volumes q 4-6 hours)
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Anxiety
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Warm nurturing environment Need to feel safe and cared for Explain procedures, equipment, changes in condition, plan of care & outcomes Communication with intubated patients Frequent family visits when possible Personal items in room

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