Nursing Case Study

Impaired Gas Exchange r/t

Behaviors:

Oxygen Saturation that falls as low as 91% on room air at rest and after exertion

After two to three minutes on Nasal Cannula of 2 Liters, Oxygern Saturation rises to 97 or 98%

Pt is out of breath and physically tired after getting up to the bathroom and shower

Rhonchi auscultated in the right middle and lower lobes

Desired Outcomes:

The patient's oxygen saturation will be kept above 96% throughout the entire shift

The patient will be able to tolerate ambulation to the bathroom and to the shower with minimal shortness of breath

Nursing Interventions:

1. Monitor the patient's oxygen saturation frequently (once per hour) at rest and after exertion on room air

2. Place patient on nasal cannula of 2 liters if oxygen saturation is below 96%

3. Monitor respiratory patterns and auscultate lung sounds

4. Place patient in a position that would facilitate easy breathing (Head of Bed 30 degrees)

5. Schedule nursing care to provide rest and minimize fatigue

Rationale:

1. Using a pulse oximetry will enable the nurse to assess the status of the patient and if she is receiving enough oxygen. Check on room air to observe how the patient is adapting on her own. It is also important to assess the oxygen saturation after activity to observe how the patient adapts to increased oxygen demand.

2. A low flow of oxygen will help the patient to receive a greater amount of oxygen and lessen the demand

3. Fluid in the lungs and interstitial space is common in patients with CHF. It is important to listen to breath sounds so that measures can be taken to prevent this early

4. A position in which the head of the bed is elevated will aid the patient in breathing so that less pressure is on the diaphragm

5. By performing a bulk of the nursing care at one time, it will allow the patient to rest between

instead of being bothered and fatigued several times in one hour.

Evaluation:

Decreased tissue perfusion r/t Impaired cardiac function

Behaviors:

Oxygen saturation has been consistently low indicating a low amount of oxygenated blood available to the tissues

The patient's capillary refill is slightly over three seconds in upper and lower extremities

The patient's pulses are weak in both upper and lower extremities