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This Concept Map, created with IHMC CmapTools, has information related to: ADN201 Nursing Process Group Project 2, RESOLVE OR REVISE, Evaluation #1b Goal Met: The client has been maintaining a SpO2 level of 95% to 100% while on the ventilator. Discontinue outcome WAYS TO RESOLVE Nursing Intervention #1b Assessment: I: The nurse will monitor oxygen saturation continuously using pulse oximetry. R: An oxygen saturation of less than 90% (normal being 95% to 100%) indicates significant oxygenation problems. (Kozier p.567) Independent: I: The nurse will position the client in a semi- fowlers position, with an upright posture at 45 degrees if possible. R: Being at a 45 degree angle while on a ventilator, increases oxygenation and ventilation. (Kozier p.1149) Dependent: See Dependent 1a Teaching: See Teaching 1a Collaborative: I: The nurse will collaborate with respiratory therapy, physician, and Xray to verify proper tube placement. R: Maintaning the enotracheal tube is an essential part of airway management. (Brunner p.515), Nursing Dx #1 Impaired Gas Exchange R/T Ventilator - Perfusion Mismatch Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. (Wittman-Price p. 441) RESULTS IN Outcome #1c The client will have ABG's within normal limits within 24hrs., Evaluation #2a Goal Met: The client maintained a patent airway due to secretions being suctioned prior to accumalation. Discontinue outcome WAYS TO RESOLVE, Outcome #3a The client will maintain skin integrity until discharge date. LEADS YOU TO DEVELOP, Outcome #2c The client will demonstrate imporved comfort and ease of breathing 24hrs after be extubated. LEADS YOU TO DEVELOP, Outcome #1b The client will maintain an SpO2 level of 95% or greater while they are on the ventilator LEADS YOU TO DEVELOP, WAYS TO RESOLVE ETIOLOGY, WAYS TO RESOLVE ETIOLOGY, Nursing Dx #3 Impaired Tissue Integrity R/T Impaired Physical Mobility Definition: Damage to musous membrane, corneal, integumentarty,or subcutaneous tissues. (Wittman-Price p. 463) RESULTS IN Outcome #3a The client will maintain skin integrity until discharge date., WAYS TO RESOLVE ETIOLOGY, RESOLVE OR REVISE, WAYS TO RESOLVE ETIOLOGY, Outcome #3b The client will maintain tissue integrity AEB absence of redness & irritation & no signs of skin breakdown by discharge date. LEADS YOU TO DEVELOP, WAYS TO RESOLVE ETIOLOGY ???? Nursing Intervention #1c Assessment: I: The nurse will assess and monitor the client for symptoms of respiratory failure. R: Changes in pulmonary status indicates improvement or onset of complications. (Brunner p.530) Independent: I: The nurse will analyze and respond to ABG results and end-tidal CO2 levels. R: Ventilator support must be closely monitored to ensure adequate oxygenation and acid- base balance. (Kozier p.1475) Dependent: I: The nurse will administer perscribed analgesics and sedatives as needed to facilitate client comfort and rest. R: Nurse implemented sedation protocol decreases the number of days of intubation, the need for a tracheostomy and the length of hospital stay. (Brunner p.526) Teaching: I: The nurse will instruct the client on how to perform deep breathing and coughing techniques. R: Deep breathing and coughing help to raise the intrapleural pressure, which promotes drainage of accumulated fluid. (Brunner p.530) Collaborative: See Collaborative 1a, LEADS TO, Pertinent Labs: Day 2 1330hrs ABG's: pH 7.3, O2 48, C02 55 HCO3 30 LEADS TO, RESOLVE OR REVISE, Nursing Intervention #2c Assessment: I: The nurse will assess the client's ability to deep breathe and cougn effectively R: Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. (Kozier p.1390) Independent: I: The nurse will encourage the client to have an fluid intake of up to 2500ml/day within cardiac or renal reserve. R: Fluids help to minimize mucosal drying and maximize ciiary action to move secretions. (Kozier p.1390) Dependent: I: The nurse will administer bronchodilators as ordered by the physician. R: Bronchodilators decrease airway resistance, improve the efficiency or respiratory movements, improve exercise tolerance & can reduce symptoms of dyspnea on exertion. (Kozier p.1391) Teaching: I: The nurse will teach the importance of not smoking and refer the client to a smoking cessaton program. R: Prolonged counseling support programs are effective in promoting long-term abstinence from smoking. (Brunner p.734) Collaborative: I: The nurse will collaborate with the physician and respiratory therapists in determining the appropriateness of noninvasive positive pressure ventiation for the decompensated COPD client. R: A collabrative approach to caring for Mechanically ventilated clients has been demonstrated to reduce length of time on the ventilator. (Brunner p.519), Outcome #1a The client will be extubated with in 48 hrs LEADS YOU TO DEVELOP