Nursing Care Plans Diagnosis: Impaired Oral mucous membraneDefinition: Disruptions of the lips and soft tissues of the oral cavity Defining Characteristics: Purulent drainage or exudates; gingival recession, pockets deeper than 4 mm; enlarged tonsils beyond what is developmentally appropriate; smooth atrophic, sensitive tongue; geographic tongue; mucosal denudation; presence of pathogens; difficult speech; self-report of bad taste; gingival or mucosal pallor; oral pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules; white patches/plaques, spongy patches, or white curd-like exudate; oral lesions or ulcers; halitosis; edema; hyperemia; desquamation; coated tongue; stomatitis; selfreport of difficult eating or swallowing; self-report of diminished or absent taste; bleeding; macroplasia; gingival . hyperplasia; fissures, cheilitis; red or bluish masses Related Factors: Chemotherapy; chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); depression; immunosuppression; aging-related loss of connective, adipose, or bone tissue; barriers to professional care; cleft lip or palate; medication side effects; lack of or decreased salivation; chemical trauma (e.g., acidicfoods , drugs, noxious agents, alcohol); pathological conditions—oral cavity (radiation to head or neck); NPO for more than 24 hours; mouth breathing; malnutrition or vitamin deficiency; dehydration; infection; ineffective oral hygiene; mechanical (e.g., illfitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); decreased platelets; immunocompromised; impaired salivation; radiation therapy; barriers to oral self-care; diminished hormone levels (women); stress; loss of supportive structures (NOC Outcomes (Nursing Outcomes Classification Suggested NOC Labels Oral Health • Tissue Integrity: Skin and Mucous Membranes • Client Outcomes Maintains intact, moist oral mucous membranes that are free of ulceration and debris • Describes or demonstrates measures to regain or maintain intact oral mucous membranes • (NIC Interventions (Nursing Interventions Classification Suggested NIC Labels Oral Health Restoration • Nursing Interventions and Rationales Inspect oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer • to a physician or specialist as appropriate. Oral inspection can reveal signs of oral disease, symptoms of systemic .disease, drug side effects, or trauma of the oral cavity Assess for mechanical agents such as ill-fitting dentures or chemical agents such as frequent exposure to tobacco that • could cause or increase trauma to oral mucous membranes. Irritative and causative agents for stomatitis should be . eliminated Monitor client's nutritional and fluid status to determine if adequate. Refer to the care plan for Deficient Fluid volume • or Imbalanced Nutrition: less than body requirements if applicable. Dehydration and malnutrition predispose clients to .impaired oral mucous membranes Encourage fluid intake up to 3000 ml per day if not contraindicated by client's medical condition (Rhodes, McDaniel, • Johnson, 1995). Fluids help increase moisture in the mouth, which protects the mucous membranes from damage and .helps the healing process Determine client's mental status. If client is unable to care for self, oral hygiene must be provided by nursing • .personnel. Thenursing diagnosis Bathing/Hygiene Self-care deficit is then also applicable Determine client's usual method of oral care and address any concerns regarding oral hygiene. Whenever possible, • .build on client's existing knowledge base and current practices to develop an individualized plan of care If client does not have a bleeding disorder and is able to swallow, encourage to brush teeth with a soft pediatric-sized • toothbrush using a fluoride-containing toothpaste after every meal and to floss teeth daily. The toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling do not use commercial mouthwashes containing alcohol or • hydrogen peroxide. Also. and swab out the mouth of the edentulous • client. and the client is prone to bleeding gums.If necessary. soft or liquid diet) may also be necessary to prevent friction trauma. • and removed and kept in an appropriate solution at night. Alcohol dries the oral mucous membranes Hydrogen peroxide can damage oral mucosa and is extremely foul tasting to clients (Tombes. Denture plaque-containing candidiasis can cause denture-induced stomatitis.Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture. do not use lemon-glycerin swabs.g. Keep lips well lubricated using petroleum jelly or a similar product • For clients with stomatitis. or a raised granular lesion.Refer to Impaired Dentition if the client has problems with the teeth • Geriatric Carefully observe oral cavity and lips for abnormal lesions such as white or red patches. masses. as well as erosion of tooth enamel Use foam sticks to moisten the oral mucous membranes.reinforcement of oral care are important to oral outcomes Top of Form Nursing Diagnosis: Ineffective airway clearance (NOC Outcomes (Nursing Outcomes Classification . increase frequency of oral care up to every hour while awake if necessary.Instruct client in ways to soothe the oral cavity • . they are .. which can cause nosocomial pneumonia If mouth is severely inflamed and it is painful to swallow. Modification of oral intake (e.bacterial colonization. diabetes.If client often breathes by mouth. ulcerations with an • indurated margin.. and many elderly persons rarely visit a dentist Ensure that dentures are removed and scrubbed at least once daily.client's discomfort . Sodium chloride rinses have been shown to be effective for the . Malignant lesions are more common in elderly persons than in younger . . Cultures of the teeth of critically ill clients have yielded significant • . or immunosuppressive . which can result in erosions. steroid therapy. refer for home health aide services to support family in oral care and observation of the oral cavity • Client/Family Teaching Teach client how to inspect the oral cavity and monitor for signs and symptoms of infection.healing Teach how to implement a personal plan of oral hygiene including a schedule of care. Oral candidiasis (moniliasis) is extremely common secondary to antibiotic therapy.. leaving a red • base that bleeds. This is an evidence-based protocol for denture care.periodontal disease Use tap water or normal saline to provide oral care.g. Gallucci. However.drugs and should be treated with oral or systemic antifungal agents . clean out debris.If client is unable to swallow. add humidity to room unless contraindicated • . Studies have shown that foam sticks are probably not effective for removing plaque from teeth. the keep inside of the mouth moist with frequent sips of water and salt water rinses (1/2 tsp • salt in 8 oz of warm water) or artificial saliva. and • . 1993.prevention and treatment of stomatitis .or hydrogen peroxide-based commercial products for mouth care and to avoid other • irritants to the oral cavity (e. Oral irritants can further damage the oral mucosa and increase the . . complications. 1994).persons (especially if there is a history of smoking or alcohol use). contact the physician for a topical anesthetic agent or • analgesic order.Thenursing diagnosis Imbalanced Nutrition: less than body requirements may apply If whitish plaques are present in the mouth or on the tongue and can be rubbed off readily with gauze. suspect a fungal infection and contact the physician for follow-up. tobacco. which is more common with unhealthy lifestyles . Increasing the • . removed and rinsed thoroughly after every meal.useful for cleaning the mouth of the edentulous client If client's oral cavity is dry. and poor oral hygiene than otherwise Home health Care Interventions Instruct client to avoid alcohol. or lesions. HIV infection. Winslow. keep suction nearby when providing oral care • . Do not use to clean the teeth or else the platelet count is very low.frequency of oral care has been shown to be effectively decrease stomatitis Provide scrupulous oral care to critically ill clients. Encouragement and • . fissures. Moisture promotes the cleansing effect of saliva and helps avert mucosal drying. spicyfoods). pneumonia. or neuromuscular weakness. the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma. wheezes• Changes in respiratory rate or depth• Cough• Hypoxemia/cyanosis• Dyspnea• Chest wheezing• Fever• Tachycardia• :Related Factors Decreased energy and fatigue• Ineffective cough• Tracheobronchial infection• (Tracheobronchial obstruction (including foreign body aspiration• Copious tracheobronchial secretions• Perceptual/cognitive impairment• Impaired respiratory muscle function• Trauma• Expected Outcomes . Ineffective airway clearance can be an acute (e.Suggested NOC Labels Respiratory Status: Airway Patency • (NIC Interventions (Nursing Interventions Classification Suggested NIC Labels Cough Enhancement Airway Management Airway Suctioning • • • NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency Maintaining a patent airway is vital to life. bronchitis.. However.. are at high risk :Defining Characteristics (Abnormal breath sounds (crackles.g.g. Likewise. who have an increased incidence of emphysema and a higher prevalence of .. from cerebrovascular accident [CVA] or spinal cord injury) problem. Elderly patients. Factors such as anesthesia and dehydration can affect function of the mucociliary system. rhonchi. respiratory muscle fatigue. conditions that cause increased production of secretions (e. macrophages. and the lymphatics. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system. and chemical irritants) can overtax these mechanisms. Coughing is the main mechanism for clearing the airway. postoperative recovery) or chronic (e.chronic cough or sputum production.g. note quality. Increases in • .clear or white). rate. and consistency. Consider possible causes for ineffective cough (e. especially in cases of trauma. and position for breathing. Patient education will vary depending on the acute or • .g. an odor may be present Send a sputum specimen for culture and sensitivity as appropriate. restlessness. This may be a result of • infection.Wheezing These may indicate increasing airway resistance ○ . odor.Coarse sounds These may indicate presence of fluid along larger airways ○ Assess respirations.eupnea. and/or irritability can be early • .. monitor for peak airway pressures and airway resistance. antibiotic treatment is indicated Monitor arterial blood gases (ABGs). or other condition. Increasing PaCO2 and decreasing PaO2 are signs of respiratory • . Increasing lethargy. color. confusion. Fever may develop in response to retained secretions/atelectasis Assess cough for effectiveness and productivity. as evidenced by clear lung sounds.Patient's secretions are mobilized and airway is maintained free of secretions. Maintaining the airway is always the first priority. dyspnea on exertion. Postoperative pain can result in shallow breathing and an ineffective cough • • If patient is on mechanical ventilation.these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation Assess patient’s knowledge of disease process.breathing. chronic smoking.• . Respiratory infections increase the work of . A sign of infection is discolored sputum (no longer .signs of cerebral hypoxia Assess changes in vital signs and temperature. or thick tenacious secretions Note presence of sputum. or cardiac arrest :Auscultate lungs for presence of normal or adventitious breath sounds. • .failure . • . use of accessory muscles. flaring of nostrils.obstruction .acute neurological decompensation. severe bronchospasm. depth. bronchitis. Abnormality indicates respiratory compromise Assess changes in mental status. as in the following Decreased or absent breath sounds These may indicate presence of mucus plug or other major airway ○ . amount.splinting.chronic disease state as well as the patient’s cognitive level . and ability to effectively cough up secretions after treatments and deep breaths Ongoing Assessment Assess airway for patency. assess quality.work of breathing.(respiratory muscle fatigue. pattern. evidence of • . Tachycardia and hypertension may be related to increased • .Assess for pain. coughing by increasing abdominal pressure and upward diaphragmatic movement Use positioning (if tolerated. head of bed at 45 degrees. which would cause respiratory embarrassment :If cough is ineffective.(aureus [MRSA] or tuberculosis .Use humidity (humidified oxygen or humidifier at bedside). This prevents suction-related hypoxia Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient○ .may cause the abdomen to compress the diaphragm. thick mucus plugs.Assist patient in performing coughing and breathing maneuvers. use nasotracheal suctioning as needed .Use soft rubber catheters. routinely check the patient’s position so he or she does not slide down in bed.(from a specific side (right versus left lung Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure○ . ambulation). These promote better • . If sputum is purulent. and mask as appropriate.should be instituted before receiving the culture and sensitivity report Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of . goggles. The sitting position and splinting the abdomen promote more effective .experiences bradycardia. These improve productivity of the cough :Instruct patient in the following (Optimal positioning (sitting position○ Use of pillow or hand splints when coughing○ Use of abdominal muscles for more forceful cough○ Use of quad and huff techniques○ Use of incentive spirometry○ Importance of ambulation and frequent position changes○ Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times..lung expansion and improved air exchange If patient is bedridden. sitting in chair.and use supplemental oxygen as appropriate.weakness. precautions ○ . an increase in ventricular ectopy. and/or desaturation Use universal precautions: gloves.Explain procedure to patient○ .g. or excessive mucus production Institute appropriate isolation precautions for positive cultures (e. This prevents trauma to mucous membranes ○ Use curved-tip catheters and head positioning (if not contraindicated). This • . This loosens secretions • • • • . methicillin-resistant Staphylococcus • . These facilitate secretion removal ○ .Therapeutic Interventions . deep breathing. instruct caregivers regarding cough enhancement techniques and need for humidification • • • Instruct caregivers in suctioning techniques.Institute suctioning of airway as determined by presence of adventitious sounds○ . Provide opportunity for return demonstration.conservation techniques. antibiotics. noting • . Increased fluid intake reduces the • viscosity of mucus produced by the goblet cells in the airways. anticipate the need for an artificial airway (intubation).rationale and appropriate techniques to keep the airway clear of secretions .In home setting.Use sterile saline instillations during suctioning.secretions with coughing Administer medications (e. Adapt technique • . at least 1 hour after eating). After intubation . This obtains lavage samples for culture and sensitivity.Encourage oral intake of fluids within the limits of cardiac reserve. and splinting techniques.or nebulizer as prescribed Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and • home care/rehabilitation environments).for home setting .chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning Coordinate optimal time for postural drainage and percussion (i. bronchodilators. Patient will understand the • . This helps facilitate removal of tenacious sputum ○ .effectiveness and side effects For patients with chronic problems with bronchoconstriction. This prevents .For patients with complete airway obstruction. Chest physiotherapy includes the techniques of postural drainage and .Instruct patient how to use prescribed inhalers. as appropriate . Maintain planned rest periods.g.e.aspiration For patients with reduced energy.Instruct patient on indications for. and • . It is easier for the patient to mobilize thinner . and side effects of medications . institute cardiopulmonary resuscitation (CPR) maneuvers • • Education/Continuity of Care Demonstrate and teach coughing. expectorants) as ordered.removes mucus plugs :If secretions cannot be cleared. mucolytic agents. assist with bronchoscopy. Fatigue is a contributing factor to ineffective coughing For acute problem. pace activities... Promote energy• . frequency. instruct in use of metered-dose inhaler (MDI) • . Smoking contributes to bronchospasm and • . This may also be useful for the patient with bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the . or neuromuscular weakness.Refer to pulmonary clinical nurse specialist. conditions that cause increased production of secretions (e.inability to adequately clear them . Ineffective airway clearance can be an acute (e. postoperative recovery) or chronic (e. macrophages. Coughing is the main mechanism for clearing the airway. Nicorette Gum.Teach patient about environmental factors that can precipitate respiratory problems • Explain effects of smoking.increased mucus production in the airways Refer patient and/or significant others to smoking-cessation group. pneumonia. bronchitis.g.chronic cough or sputum production. respiratory muscle fatigue. or respiratory therapist as indicated Top of Form • • Nursing Diagnosis: Ineffective airway clearance (NOC Outcomes (Nursing Outcomes Classification Suggested NOC Labels Respiratory Status: Airway Patency • (NIC Interventions (Nursing Interventions Classification Suggested NIC Labels Cough Enhancement Airway Management Airway Suctioning • • • NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency Maintaining a patent airway is vital to life.g. as appropriate. • instruct caregiver in chest physiotherapy as appropriate. are at high risk . Factors such as anesthesia and dehydration can affect function of the mucociliary system. and chemical irritants) can overtax these mechanisms..of smoking-cessation aids (e. neuromuscular impairment. the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma. who have an increased incidence of emphysema and a higher prevalence of . or Habitrol) to wean off the effects of nicotine . and the lymphatics. Likewise. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system. and discuss potential use • . Elderly patients... including second-hand smoke. However. from cerebrovascular accident [CVA] or spinal cord injury) problem.g. Nicoderm..g.For patients with debilitating disease being cared for at home (CVA. and others). home health nurse.Instruct patient on warning signs of pending or recurring pulmonary problems . evidence of • . confusion. • . note quality. wheezes• Changes in respiratory rate or depth• Cough• Hypoxemia/cyanosis• Dyspnea• Chest wheezing• Fever• Tachycardia• :Related Factors Decreased energy and fatigue• Ineffective cough• Tracheobronchial infection• (Tracheobronchial obstruction (including foreign body aspiration• Copious tracheobronchial secretions• Perceptual/cognitive impairment• Impaired respiratory muscle function• Trauma• Expected Outcomes Patient's secretions are mobilized and airway is maintained free of secretions. and/or irritability can be early • . rhonchi. or cardiac arrest :Auscultate lungs for presence of normal or adventitious breath sounds. and position for breathing. rate. flaring of nostrils.• . Maintaining the airway is always the first priority. use of accessory muscles. and ability to effectively cough up secretions after treatments and deep breaths Ongoing Assessment Assess airway for patency.:Defining Characteristics (Abnormal breath sounds (crackles. dyspnea on exertion. as in the following Decreased or absent breath sounds These may indicate presence of mucus plug or other major airway ○ .splinting.eupnea. especially in cases of trauma.Coarse sounds These may indicate presence of fluid along larger airways ○ Assess respirations. restlessness. depth. as evidenced by clear lung sounds.Wheezing These may indicate increasing airway resistance ○ .obstruction . Abnormality indicates respiratory compromise Assess changes in mental status. pattern.signs of cerebral hypoxia • . Increasing lethargy.acute neurological decompensation. or thick tenacious secretions Note presence of sputum. monitor for peak airway pressures and airway resistance. These improve productivity of the cough :Instruct patient in the following (Optimal positioning (sitting position○ Use of pillow or hand splints when coughing○ Use of abdominal muscles for more forceful cough○ Use of quad and huff techniques○ Use of incentive spirometry○ Importance of ambulation and frequent position changes○ Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the coughing is done at varying times. A sign of infection is discolored sputum (no longer . or other condition.. and consistency. The sitting position and splinting the abdomen promote more effective . Patient education will vary depending on the acute or • . head of bed at 45 degrees. an odor may be present Send a sputum specimen for culture and sensitivity as appropriate. Consider possible causes for ineffective cough (e.Assess changes in vital signs and temperature. These promote better • . color. • . assess quality. antibiotic treatment is indicated Monitor arterial blood gases (ABGs). bronchitis.(respiratory muscle fatigue. ambulation).lung expansion and improved air exchange • • . This may be a result of • infection. chronic smoking.Assess for pain.chronic disease state as well as the patient’s cognitive level Therapeutic Interventions .coughing by increasing abdominal pressure and upward diaphragmatic movement Use positioning (if tolerated.g. Respiratory infections increase the work of .breathing.these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation Assess patient’s knowledge of disease process. severe bronchospasm.Assist patient in performing coughing and breathing maneuvers. Postoperative pain can result in shallow breathing and an ineffective cough • If patient is on mechanical ventilation.work of breathing.failure . Tachycardia and hypertension may be related to increased • . Fever may develop in response to retained secretions/atelectasis Assess cough for effectiveness and productivity. odor. Increases in • . Increasing PaCO2 and decreasing PaO2 are signs of respiratory • .clear or white). sitting in chair. amount. or excessive mucus production Institute appropriate isolation precautions for positive cultures (e.aspiration For patients with reduced energy. These facilitate secretion removal ○ . This prevents trauma to mucous membranes ○ Use curved-tip catheters and head positioning (if not contraindicated)..should be instituted before receiving the culture and sensitivity report Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of . use nasotracheal suctioning as needed . routinely check the patient’s position so he or she does not slide down in bed. and/or desaturation Use universal precautions: gloves.chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning Coordinate optimal time for postural drainage and percussion (i.Explain procedure to patient○ . goggles.e.may cause the abdomen to compress the diaphragm. precautions ○ . mucolytic agents.conservation techniques. Increased fluid intake reduces the • viscosity of mucus produced by the goblet cells in the airways. Fatigue is a contributing factor to ineffective coughing . noting • . antibiotics.If patient is bedridden.weakness.. at least 1 hour after eating). This loosens secretions • • Encourage oral intake of fluids within the limits of cardiac reserve.effectiveness and side effects For patients with chronic problems with bronchoconstriction. Maintain planned rest periods. an increase in ventricular ectopy. bronchodilators. instruct in use of metered-dose inhaler (MDI) • . Promote energy• .g.or nebulizer as prescribed Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and • home care/rehabilitation environments).secretions with coughing Administer medications (e. This • . which would cause respiratory embarrassment :If cough is ineffective. methicillin-resistant Staphylococcus • . thick mucus plugs. If sputum is purulent. pace activities.(from a specific side (right versus left lung Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure○ . It is easier for the patient to mobilize thinner .Use humidity (humidified oxygen or humidifier at bedside). This prevents suction-related hypoxia Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient○ .experiences bradycardia. Chest physiotherapy includes the techniques of postural drainage and . This prevents .and use supplemental oxygen as appropriate.(aureus [MRSA] or tuberculosis . expectorants) as ordered.g.. and mask as appropriate.Use soft rubber catheters. Use sterile saline instillations during suctioning. and discuss potential use • .Instruct patient on indications for. and others).rationale and appropriate techniques to keep the airway clear of secretions . frequency. assist with bronchoscopy. home health nurse. and side effects of medications . including second-hand smoke. neuromuscular impairment. Smoking contributes to bronchospasm and • .for home setting For patients with debilitating disease being cared for at home (CVA. and • .Instruct patient how to use prescribed inhalers.In home setting. Patient will understand the • . or Habitrol) to wean off the effects of nicotine . • instruct caregiver in chest physiotherapy as appropriate.g. as appropriate. instruct caregivers regarding cough enhancement techniques and need for humidification • • • Instruct caregivers in suctioning techniques. or respiratory therapist as indicated (Nursing Care Plan of patient with Respiratory Acidosis (Primary Carbonic Acid Excess• • • • . This obtains lavage samples for culture and sensitivity. Provide opportunity for return demonstration.removes mucus plugs :If secretions cannot be cleared. and splinting techniques.. as appropriate .Teach patient about environmental factors that can precipitate respiratory problems • Explain effects of smoking.Institute suctioning of airway as determined by presence of adventitious sounds○ .Refer to pulmonary clinical nurse specialist.Instruct patient on warning signs of pending or recurring pulmonary problems .of smoking-cessation aids (e. After intubation . deep breathing. This helps facilitate removal of tenacious sputum ○ . This may also be useful for the patient with bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the . Nicoderm. anticipate the need for an artificial airway (intubation).For patients with complete airway obstruction. institute cardiopulmonary resuscitation (CPR) maneuvers • • Education/Continuity of Care Demonstrate and teach coughing. Adapt technique • . Nicorette Gum.increased mucus production in the airways Refer patient and/or significant others to smoking-cessation group.For acute problem.inability to adequately clear them . acidosis can be due to/associated with primary defects in lung function or changes in normal . overdose of sedatives/barbiturate poisoning. cerebral vascular accident [CVA] therapy).. aspiration of foreign body. asthma. bronchiectasis. mixed acid-base imbalances are more common (e.g. mechanical ventilators.. spinal cord injuries CARE SETTING This condition does not occur in isolation. acute laryngospasm. excessive CO2 intake (e.45. anesthesia/surgery.35–7. Although simple acid-base imbalances (e. adult respiratory distress syndrome (ARDS). forming bicarbonate ions and deoxygenated Hb. the .respiratory pattern.g Cerebrovascular accident (CVA)/stroke Chronic obstructive pulmonary disease (COPD) and asthma (Craniocerebral trauma (acute rehabilitative phase Eating disorders: obesity Alcohol: acute withdrawal (Spinal cord injury (acute rehabilitative phase Surgical intervention (Ventilatory assistance (mechanical OTHER CONCERNS Fluid and electrolyte imbalances Metabolic acidosis Metabolic alkalosis .syndrome Chronic respiratory acidosis: Associated with emphysema. (2) hemoglobin (Hb) buffering. but rather is a complication of a broader health problem/disease or condition for which the severely compromised patient requires admission to a medical-surgical or .subacute unit RELATED CONCERNS :..reabsorption of bicarbonate Acute respiratory acidosis: Associated with acute pulmonary edema.Plans of care specific to predisposing factors/disease or medical condition.g. and (3) increased renal ammonia acid excretions with . It does so by means of chemical buffering mechanisms involving the lungs and kidneys. atelectasis. respiratory acidosis) do occur. The disorder may be acute or chronic Compensatory mechanisms include (1) an increased respiratory rate.RESPIRATORY ACID-BASE IMBALANCES• The body has the remarkable ability to maintain plasma pH within a narrow range of 7. neuromuscular disorders . hemothorax/pneumothorax.(respiratory acidosis/metabolic acidosis that occurs with cardiac arrest (RESPIRATORY acidosis (Primary carbonic acid EXCESS Respiratory acidosis (elevated PaCO2 level) is caused by hypoventilation with resultant excess carbonic acid (H2CO3). use of rebreathing mask.(such as Guillain-Barré syndrome and myasthenia gravis). e. botulism. Pickwickian . smoke inhalation.g. irregular pulse (other/various dysrhythmias (Diaphoresis. mild to profound May exhibit: Generalized weakness. metabolic alkalosis Adventitious breath sounds (crackles. pinkish color. wheezes). decreased in respiratory center depression/ muscle paralysis.9 days May require assistance with changes in therapies for underlying disease process/condition . use of neck and upper body muscles Decreased respiratory rate/hypoventilation (associated with decreased function of respiratory center as in (head trauma. restlessness.Refer to section at end of plan for postdischarge considerations . dyspnea with exertion May exhibit: respiratory rate dependent on underlying cause. somnolence.Patient Assessment Database . agitation. warm skin (reflects vasodilation of (severe acidosis (Tachycardia. visual disturbances (May exhibit: Confusion. decreased reflexes (severe RESPIRATION May report: Shortness of breath.Dependent on underlying cause. and cyanosis (late stage FOOD/FLUID May report: Nausea/vomiting NEUROSENSORY (May report: Feeling of fullness in head (acute—associated with vasodilation Headache. loss of coordination (chronic). otherwise rate is rapid/shallow Increased respiratory effort with nasal flaring/yawning.Refer to specific plans of care reflecting individual predisposing/contributing factors Discharge plan DRG projected mean length of inpatient stay: 4. apprehension. oversedation. crowing TEACHING/LEARNING . to stupor CIRCULATION May exhibit: Low BP/hypotension with bounding pulses. pallor. stridor. general anesthesia. Findings vary widely ACTIVITY/REST May report: Fatigue. coma (acute (Tremors.e.. ataxia/staggering. dizziness. i. greater than 26 mEq/L (compensated/chronic stage .2 .3 DISCHARGE GOALS . prognosis.plan in place to meet needs after discharge • •المصدر: منتديات جازان التمريضية . greater than 45 mm Hg (Primary acidosis .2 .DIAGNOSTIC STUDIES .Free of complications .1 .Physiological balance restored .3 .35 . less than 7.1 .ABGs: PaO2: Normal or may be low.Prevent/minimize complications .(Bicarbonate (HCO3): Normal or increased. and treatment needs understood .Achieve homeostasis . search• • Catechol• • • dopamine• • .Arterial pH: Decreased.(PaCO2: Increased.Other screening tests: As indicated by underlying illness/condition to determine underlying cause NURSING PRIORITIES .Urinalysis: Urine pH decreased .Electrolytes: Serum potassium: Typically increased .Condition. Oxygen saturation (SaO2) decreased .Provide information about condition/prognosis and treatment needs as appropriate .Lactic acid: May be elevated .Serum chloride: Decreased .4 • Jump to: navigation.Serum calcium: Increased . Here. They are derived• [ from the amino acid tyrosine.part of the sympathetic nervous system They are called catecholamines because they contain a catechol or 3. all of which are produced from phenylalanine and tyrosine. (Tyrosine is• also ingested directly from dietary protein).4-dihydroxyphenyl group. the most abundant catecholamines are epinephrine (adrenaline).drugs are catecholamine analogs . to dopamine. and eventually to epinep • .[2 In the human body.[1] They are• .• (norepinephrine (noradrenaline• • • (epinephrine (adrenaline• Catecholamines are "fight-or-flight" hormones released by the adrenal glands in response to stress. to norepinephrine. so they circulate in the bloodstream• Tyrosine is created from phenylalanine by hydroxylation by the enzyme phenylalanine hydroxylase.Catecholamines are water-soluble and are 50% bound to plasma proteins. It is then sent to catecholamine-secreting neurons. Various stimulant . several reactions serially convert tyrosine to L-DOPA. norepinephrine• (noradrenaline) and dopamine. Bottom of . Bottom of Form .