Docsity
Docsity
Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity

Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan

Guidelines and tips
Guidelines and tips
Sell on Docsity
Sell on Docsity
Docsity AI
Docsity AI
Log inSign up

Prepare for your exams

Study with the several resources on Docsity

Find documents

Prepare for your exams with the study notes shared by other students like you on Docsity

Search for your university

Find the specific documents for your university's exams

Docsity AINEW

Summarize your documents, ask them questions, convert them into quizzes and concept maps

Explore questions

Clear up your doubts by reading the answers to questions asked by your fellow students

Earn points to download

Earn points by helping other students or get them with a premium plan

Share documents
download point icon20 Points

For each uploaded document

Answer questions
download point icon5 Points

For each given answer (max 1 per day)

All the ways to get free points
Get points immediately

Choose a premium plan with all the points you need

Study Opportunities

Choose your next study program

Get in touch with the best universities in the world. Search through thousands of universities and official partners

Community

Ask the community

Ask the community for help and clear up your study doubts

Free resources

Our save-the-student-ebooks!

Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors

NR 341 Week 2 Edapt Assignment, Assignments of Nursing

Chamberlain College of NursingNursing

NR 341 Week 2 Edapt Assignment

Typology: Assignments

2024/2025

Available from 06/15/2025

Milestonee
Milestonee 🇺🇸

4.2

(33)

4.3K documents

1 / 9

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
EDAPT WEEK 2 NR341
Nursing Care: Complex Oxygenation Alterations
For some clients with severe, chronic emphysema, the stimulus to breathe is a low serum oxygen
level (the normal stimulus is a high carbon dioxide level). This client’s oxygen flow is too high,
causing a high serum oxygen level, resulting in a decreased respiratory rate. If the nurse does not
intervene, the client is at risk of respiratory arrest.
Assessment
Assess the severity of respiratory distress by noting respiratory rate, respiration
characteristics (shallow, irregular), SpO2, use of accessory muscles, client position, ability
to speak, skin color, and skin temperature.
•Review arterial blood gas analysis.
•Assess for agitation, restlessness, level of anxiety, confusion, and restlessness.
•Assess the lungs for areas of decreased ventilation and auscultate presence
of adventitious sounds.
•Assess heart rate, rhythm, blood pressure, and capillary refill.
•Conduct symptom analysis of cough, sputum, and chest pain.
•Assess for manifestations reflecting chronic disease, clubbing, and
anteroposterior diameter of chest.
•Determine history reflecting respiratory health, smoking, and environmental toxins.
Diagnosis/Analysis
Related to underlying pathology
•Impaired gas exchange
•Impaired ventilation breathing
•Ineffective airway clearance
•Anxiety
Related to treatment/equipment
•Impaired verbal communication
•Risk for
infection Planning
•Client exhibits improved gas exchange as evidenced by usual mental status,
unlabored respirations, SpO2 results within normal range, ABGs within
normal range, and baseline heart rate and blood pressure.
pf3
pf4
pf5
pf8
pf9

Partial preview of the text

Download NR 341 Week 2 Edapt Assignment and more Assignments Nursing in PDF only on Docsity!

EDAPT WEEK 2 NR

Nursing Care: Complex Oxygenation Alterations For some clients with severe, chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This client’s oxygen flow is too high, causing a high serum oxygen level, resulting in a decreased respiratory rate. If the nurse does not intervene, the client is at risk of respiratory arrest. Assessment Assess the severity of respiratory distress by noting respiratory rate, respiration characteristics (shallow, irregular), SpO 2 , use of accessory muscles, client position, ability to speak, skin color, and skin temperature.

**- Review arterial blood gas analysis.

  • Assess for agitation, restlessness, level of anxiety, confusion, and restlessness.
  • Assess the lungs for areas of decreased ventilation and auscultate presence** **of adventitious sounds.
  • Assess heart rate, rhythm, blood pressure, and capillary refill.
  • Conduct symptom analysis of cough, sputum, and chest pain.
  • Assess for manifestations reflecting chronic disease, clubbing, and** **anteroposterior diameter of chest.
  • Determine history reflecting respiratory health, smoking, and environmental toxins. Diagnosis/Analysis Related to underlying pathology
  • Impaired gas exchange
  • Impaired ventilation breathing
  • Ineffective airway clearance
  • Anxiety Related to treatment/equipment
  • Impaired verbal communication
  • Risk for infection Planning
  • Client exhibits improved gas exchange as evidenced by usual mental status, unlabored respirations, SpO 2 results within normal range, ABGs within normal range, and baseline heart rate and blood pressure.**

**- Client will maintain a clear airway and demonstrate effective coughing.

  • Client demonstrates effective airway clearance as evidenced by clear lung sounds.
  • Client will exhibit normal behavior and mental status. Implementation
  • Client exhibits improved gas exchange as evidenced by usual mental status, unlabored respirations, SpO 2 results within normal range, ABGs within normal range, and baseline heart rate and blood pressure.
  • Client will maintain a clear airway and demonstrate effective coughing.
  • Client demonstrates effective airway clearance as evidenced by clear lung sounds.
  • Client will exhibit normal behavior and mental status. Evaluation
  • Analyze the client’s response to oxygen administration based on pulse oximetry readings, ABG analysis, and skin color.
  • Examine the client’s response to medication administration, noting absence of accessory muscle use, normal respiratory rate, heart rate, and blood pressure.
  • Identify factors contributing to clear lung sounds and absence of adventitious sounds.
  • Identify factors contributing to improved mental status and behavior. (Assessment includes observing the client and the surrounding environment, looking for changes. Analysis includes identifying the clinical problems to be addressed and investigating the contributing causes. Planning involves identifying achievable goals. Implementation involves providing direct care (such as oral care) and collaborating/communicating with the client, family, and healthcare team. Evaluation involves determining the client’s response to treatment (after medication administration) and progressing to the established goals of care.)** Supporting Complex Oxygenation and Breathing Needs Simple Airway Adjuncts Purpose: Maintain or open the airway; used to assist with manual ventilation using a bag-mask device and can assist with suctioning. Examples: oropharyngeal airway (OPA) and nasopharyngeal airway (NPA)

Mechanical Ventilation Purpose: Provides controlled invasive ventilation using positive or negative pressure and oxygen to facilitate inspiration and expiration to sustain life in clients unable to breathe independently. Examples: use of a ventilator

  • These are used in clients who are unable to maintain effective gas exchange; for instance, clients experiencing respiratory failure, infections (pneumonia), or fatigue (acute exacerbation of chronic obstructive pulmonary disease [COPD] or impairment of muscles used to breathe [amyotrophic lateral sclerosis, ALS]). Caution: Clients treated with mechanical ventilation are at risk for ventilator-associated pneumonia (VAP). Nursing care should adhere to standard protocol procedures to reduce this risk. (FYI: An OPA can be used to protect the client’s airway during manual ventilation and if unresponsive and the tongue is obstructing breathing. BiPAP provides ventilatory support to clients experiencing respiratory difficulty who do not require an invasive artificial airway, such as those with sleep apnea and snoring. The ETT can be used to protect or secure the client’s airway during medically emergent and non- emergent situations in a controlled environment. The LMA can protect the client’s airway or secure the airway during a medical emergency in an uncontrolled environment or trauma.) Oxygenation and Communication Physical Communication
  • Establish the client’s attention by utilizing touch and maintaining eye contact.
  • Have the client wear their prescribed glasses and hearing aids.
  • Instruct the client to use pointing and gestures in response to questions.
  • Instruct the client to nod their head in response to yes or no questions. Visual Communication
  • Designated picture boards that express a concept, routine, or client's needs can enhance communication.
  • Because of their simplicity, picture boards are also helpful for clients who are confused or not fluent in reading or writing.
  • Braille picture boards are available to promote communication with a client with limited vision who knows how to read Braille. Verbal Communication
  • Have a notebook (dry-erase board) and marker for clients to write keywords or phrases to communicate a specific message.
  • To increase the client's understanding, speak slowly, over-enunciate, and use short sentences or phrases.
  • Pause for 10 seconds to allow the client to respond.
  • Because of machine or ventilator noise, be sure to speak loud enough to be heard over the machines and alarms. Nursing Care: Chest Tubes Make sure you have sterile water or saline on hand in case the chest tubing comes loose. If it does, put the end of the tubing in sterile water or saline to fix the seal. Keep drain clamps nearby to check for air leaks. Use clamps briefly, but be careful because clamping a chest tube can cause a pneumothorax. If a chest tube is loose or comes out at the insertion site, cover the site with an occlusive gauze dressing to prevent a pneumothorax from happening again. Have emergency oxygen equipment available in case a pneumothorax happens again, as quick action is needed. Also, check hospital policies for specific details on managing chest tubes at that hospital. Pneumothorax Pneumothorax is a collection of air trapped within the pleural space. The pleural space is a cavity between the membrane linings of the lungs (visceral pleura) and the lining of the chest cavity (parietal pleura). The pleural space is normally filled with approximately 50 mL of fluid, which lubricates the opposing surfaces and maintains a negative pressure to keep the lungs expanding During pneumothorax, the pleural space is filled with air that exerts pressure on the outside of the lung. The buildup of air causes the lung to collapse, which causes all or part of the lung to have the inability to inflate fully. If only a small part of the lung is affected, clients may not experience any symptoms. If a large area is affected, clients with pneumothorax may exhibit shortness of breath, chest pain, hypoxia, decreased or absent breath sounds, and tachycardia. Risk Factors
  • smoking
  • tall, thin body in an otherwise healthy person
  • family history of spontaneous pneumothorax
  • severe chronic lung disease (asthma, chronic obstructive pulmonary disease [COPD])
  • pregnancy
  • lung infection or pneumonia

Potential Complications o Hypermetabolic state > dramatically increased nutrition requirements o Paralytic ileus o Stress ulceration and hemorrhage Interventions o Nutritional support/enteral or parental nutrition o Ulcer prevention (proton pump inhibitors [pantoprazole] and mucosal protection [sucralfate]) Potential Complications o Anemia o Disseminated intravascular coagulation (DIC) o Thrombocytopenia o Venous thromboembolism (VTE) Interventions o VTE prophylaxis to prevent clotting o Monitor complete blood count (CBC) and coagulation laboratory data Complications o Nosocomial infections o Catheter-related infection (intravenous lines, urinary catheter) Interventions o Strict adherence to standards of care for all medical devices and standard precautions Potential Complications o Acute kidney injury (AKI) due to hypoxemia, nephrotoxic drugs, low cardiac output, and hypotension

Interventions o Support/monitor cardiac output o Monitor intake and output closely (early identification) o Maintain stable blood pressure Potential Complications o Pulmonary emboli o Pulmonary fibrosis o Ventilator-associated barotrauma o Ventilator-associated pneumonia (VAP) Interventions o Ventilator-associated pneumonia (VAP) prophylaxis o Adhere to mechanical ventilation ARDS facility protocol o Provide endotracheal suctioning, as needed Pneumonia is one of the risk factors for acute respiratory failure (ARF). When present with the physical findings of worsening shortness of breath, new onset of mental status changes, and a pulse oximeter reading less than 60%, this cluster of cues suggests a client is progressing to ARF. o A slightly elevated temperature and a productive cough are non-specific indicators of a respiratory infection, such as influenza A the client is known to have.

Assessment Finding

Acute Respiratory

Failure (ARF) Pneumonia

Mild Heart

Failure

tered mental status X

Due to hypoxia

X

Due to hypoxia

X

Due to hypoxia

oductive cough and green sputum X

Reflects infection