Nursing Diagnosis & Planning: Oxygenation & Perfusion

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Questions and Answers

What is an example of impaired gas exchange?

Impaired gas exchange related to the destruction of alveolar walls, as evidenced by SpO2 of 90% and patient complaint of an inability to breathe.

What is an example of ineffective airway clearance?

Ineffective airway clearance related to bronchoconstriction and increased production of mucus, as evidenced by thick sputum, prolonged coughing incidents, adventitious breath sounds, and complaint of dyspnea.

What is an example of ineffective peripheral tissue perfusion?

Ineffective peripheral tissue perfusion related to decreased oxygen levels in the blood, as evidenced by fatigue with exercise and cyanosis.

What is an example of activity intolerance?

Activity intolerance related to low oxygen levels and the need for more oxygen with activity, as evidenced by complaints of fatigue dropping O2 saturation levels with activity and slow gait. Signup and view all the answers

What is an example of an ineffective breathing pattern?

Ineffective breathing pattern related to ineffective movement of air in and out of the lungs, as evidenced by difficulty in breathing with activity and at rest and use of pursed-lip breathing. Signup and view all the answers

What is an example of anxiety related to health status?

Anxiety related to difficulty in breathing, as evidenced by irritability and verbalization of nervousness about health status. Signup and view all the answers

What is an example of acute pain related to heart damage?

Acute pain related to damage to the heart muscle, as evidenced by pain rating at 7 out of 10, increased respiratory rate and diaphoresis. Signup and view all the answers

What should be the priority order for diagnoses?

Airway Signup and view all the answers

What are four criteria to include in patient goal statements?

Measurable Signup and view all the answers

What is an example of a measurable goal statement for a patient with decreased oxygenation?

Patient will maintain SpO2 at 92% or greater by the end of the shift. Signup and view all the answers

What will the nurse often do regarding planning for oxygenation and perfusion?

Collaborate with respiratory therapists, physical therapists, and nutrition services. Signup and view all the answers

What is used to develop individualized goals during the planning phase?

Assessment data and nursing diagnoses. Signup and view all the answers

Match the statement with the corresponding goal-writing criteria it describes:

The patient must be able to attain the goals = Realistic The goals are specifically written for the patient = Patient centered The goals are specific, with numeric parameters or other concrete criteria = Measurable The goals include a time for evaluation = Time-limited Signup and view all the answers

Based on assessment data, which nursing diagnostic label is supported by the most evidence?

Activity intolerance Signup and view all the answers

Study Notes

Impaired Gas Exchange: Caused by destruction of alveolar walls, indicated by SpO2 of 90% and patient expressing difficulty in breathing.
Ineffective Airway Clearance: Due to bronchoconstriction and excessive mucus, characterized by thick sputum, prolonged coughing, abnormal breath sounds, and dyspnea.
Ineffective Peripheral Tissue Perfusion: Related to low blood oxygen levels, shown by fatigue during exercise and cyanosis.
Activity Intolerance: Linked to low oxygen levels necessitating more oxygen during activities, reflected by fatigue, decreased O2 saturation, and slow walking pace.
Ineffective Breathing Pattern: Associated with poor air movement in and out of lungs, noted by breathing difficulties during activities and rest, alongside pursed-lip breathing.
Anxiety: Stemming from struggling to breathe, evidenced by irritability and expressed concerns about health.
Acute Pain: Resulting from heart muscle damage, indicated by pain rated at 7/10, increased respiratory rate, and sweating.

Prioritization in Nursing Diagnoses

Recommendations for prioritizing nursing diagnoses emphasize:
- Airway
- Breathing
- Circulation

Writing Goals for Patient Care

Goals for patients must include four crucial criteria:
- Realistic
- Patient-centered
- Measurable
- Time-limited

Examples of Measurable Goals for Oxygenation

Patients to maintain SpO2 of 92% or higher by shift's end.
Lung sounds to be clear upon auscultation within 24 hours.
SpO2 of 92% or more to be sustained during activities within 48 hours.
Patients to report reduced fatigue during hospitalization.
Extremities to be pink and warm after supplemental oxygen is administered.
Patients to express increased comfort, both psychological and physical, within 8 hours.
Respiratory rates to stabilize between 16-20 breaths/min post-pain medication before cardiac procedures.

Collaboration in Oxygenation and Perfusion Planning

Nurses often work with:
- Respiratory Therapists (RT)
- Physical Therapists (PT)
- Nutrition Services

Individualized Goal Development

Individualized goals are formulated using:
- Assessment data
- Nursing diagnoses

Goal-Writing Criteria Matching

Realistic goals: Patient must achieve them (C).
Patient-centered goals: Specifically tailored for the patient (A).
Measurable goals: Clear parameters provided (D).
Time-limited goals: Includes timeframe for evaluation (B).

Case Study Application

A patient with chronic respiratory issues shows:
- Fatigue and inability to perform daily activities
- Slow walking with multiple rests
- Diminished SpO2 during activity
- Elevated respiratory rate without abnormal breath sounds
- No pain reported
The most appropriate nursing diagnosis supported by evidence is Activity Intolerance (C).

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Description

This quiz focuses on nursing diagnoses related to oxygenation and perfusion concepts outlined in the Fundamentals of Nursing. It includes flashcards that provide examples and definitions of common nursing diagnoses such as impaired gas exchange and ineffective airway clearance. Prepare to test your knowledge and understanding of these critical nursing concepts.