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This Concept Map, created with IHMC CmapTools, has information related to: Randi Zwerner, Can Cause ???? Complication of, Related to Can Cause, Complication of Related to, Can Cause ???? Leads to, ACTUAL ???? Key Problem Exacerbation of COPD Nursing Diagnosis: Ineffective airway clearance related to decreased Level of consciousness, increased secretions, presence of artificial airway as evidenced by inability to cough, SPO2 ៉% on room air, and under sedation. Data: Decreased respiratory rate and SPO2, Decreased Level of consciousness, hypoxia, dyspnea, confusion. Interventions: Ventilation *Perform suctioning every hour to remove secretions *Administer humidified oxygen to prevent drying of mucous membraned *Reposition patient to maximize ventilation *Regulate fluid volume intake Medications: Versed, Fentanyl, Nimbex (sedatives + muscle relaxants) Fluids (Normal Saline), Oxygen Outcomes: Demonstrate effective airway clearance as evidenced by Aspiration prevention, improved Respiratory status: patent airway, and ventilations not comprimised. Normal Respiratory rate and rhythm. Moves sputum out of airway. Moves blockage out of airway., ACTUAL ???? Key Problem: Impaired Respiratory Status (FAILURE) Nursing Diagnosis: Impaired Gas Exchange related to Respiratory Failure as evidenced by decreased respirations and SPo2% ( ៉%) and altered Arterial Blood Gasses Data: Patient became unconscious after suffering a respiratory arrest. WBC: 22.8 ABG: PCO@ 48, HCO3 44, pH 7.53 Confusion Restlessness Dyspena Hypoxia Febrile Tachycardia Hypotension Interventions: Monitor Ventilation, tube placement, cuff, location, skin assessment. Monitor ABG's, pH, O2 saturation Frequent Neurological assessments or BIS monitors Auscultate posterior and anterior lung sounds at minimum hourly Continuous monitoring of cardiac and vital signs Outcomes: Gas exchange will not be compromised as evidenced by the following: improved cognitive status, PaO2, PaCO2, arterial pH, and O2 saturation, and entidal CO2 within normal limits. No dyspnea at rest Minimal dyspnea with exertion. Normal respiratory rate, rhythm, depth of inspiration., Leads to ACTUAL, Potential Nursing Diagnosis: ???? Key Problem: Decreased Nutritional status Nursing Diagnosis: Imbalanced Nutrition Less than Body requirements related to respiratory failure and COPD as evidenced weight loss and loss of appetite. Data: Weight loss of 10 lb Low electrolytes: Calcium, Chloride, Albumin, and Protein Blood Glucose: 189 secondary to steroids Respiratory failure led to altered level of consciousness and decreased appetite. Mechanical Ventilation caused inability to take food and or fluids orally. Interventions: Total Parenteral Nutrition Monitor and maintain nutrition by tube feeding. Monitor lab values; electrolytes, administration of protein and albumin Maintain appropriate fluid balance by IV fluids and strict Intake and Output data Daily weights Medications: Total parenteral feedings (Exata-Mix 75 ml/hr) Outcomes: Continue Tube Feeding without difficulty until able to tolerate oral intake. Will gain weight at 1 lb per week until desired body mass achieved. Have laboratory values of albumin and electrolytes within normal limits., Potential Nursing Diagnosis: Infection Decreased Mobility Impaired Skin Integrity Pain Social Isolation Ineffective Coping Activity Intolerance Aspiration Disturbed Body Image Decreased Cardiac Output Caregiver Role Strain Confusing Coping Falls Fatigue Fear Fluid Volume Imbalanced Knowledge Deficient Noncompliance (Smoking) Self-Care Deficit Sleep Deprivation Ineffective Tissue Perfusion: Cardiopulmonary Ventilatory Weaning Response, Dysfunctional