Nursing Case Study Essay

705 Words Sep 15th, 2006 3 Pages
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
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Assess patient's tissue perfusion through capillary refill and pulses
2. Monitor the patient's oxygen saturation frequently
3. Instruct the patient to reposition herself frequently and supply extra pillows for bony prominences like heels and elbows
4. Assess all areas of the skin to look for pressure ulcers and pay close attention to foot care
5. Keep the patient warm

Rationale:
1. Capillary refill and pulses will give a good indication of the kind of perfusion the patient is experiencing. By checking these on the tips of the fingers and toes, the nurse will ensure proper assessment. Prolonged capillary refill or absence of pulses can indicate a serious problem and may result in tissue ischemia
2. Oxygen saturation has a great deal to do with tissue perfusion. The less oxygen-rich blood that is able to circulate throughout the body, the less perfusion is going on and the greater the risk for ischemia.
3. Pressure ulcers are a problem for anyone who is not mobile on a regular basis. With decreased tissue perfusion, the patient is at an even greater risk for tissue breakdown. Repositioning will ensure that no spot on

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