Priority 1. Impaired gas exchange r/t altered blood flow to alveoli secondary to pulmonary embolus -Patient’s c/c
-Patient has difficulty answering questions because of dyspnea and pain.
-Patient is pale which demonstrates lack of oxygenation.
- She is restless, agitated, slightly disoriented; decrease LOC.
-Sputum is blood streaked; damage to lung tissue.
-Respiratory rates in order; 28,30,36 showing that his body is not receiving enough oxygen.
- ABG: Uncompensated respiratory alkalosis with hypoxia. Prabha is having 36 respirations per minute which is classified has hyperventilation. The lungs are offloading CO2 and unable to pick up and deliver oxygen.
-Sinus tachycardia and pulse of 124, signs that the body is trying to compensate for hypoxemia. …show more content…
-hx of smoking
-BE -3 shows that the body is trying to compensate for respiratory alkalosis. 1. Implement oxygen therapy; titrate O2 to maintain O2 sats greater than or equal to 92%. Use nasal cannula or mask. Per HCP’s orders.
2. Check v/s (pulse oximetry, lung sounds (listen for adventitious sounds) and cardiac and respiratory status at least every 30 minutes) (Ackley & Ladwig, 2014).
3. Diligently monitor RR, depth, and effort, along with signs of distress.
4. Perform physical assessment, document, contact HP if abnormal.
5. Establish patient’s baseline LOC and use it to monitor how interventions are working.
6. Place patient in a semi to high-fowlers position to maximize thoracic expansion and reduce
-Patient has difficulty answering questions because of dyspnea and pain.
-Patient is pale which demonstrates lack of oxygenation.
- She is restless, agitated, slightly disoriented; decrease LOC.
-Sputum is blood streaked; damage to lung tissue.
-Respiratory rates in order; 28,30,36 showing that his body is not receiving enough oxygen.
- ABG: Uncompensated respiratory alkalosis with hypoxia. Prabha is having 36 respirations per minute which is classified has hyperventilation. The lungs are offloading CO2 and unable to pick up and deliver oxygen.
-Sinus tachycardia and pulse of 124, signs that the body is trying to compensate for hypoxemia. …show more content…
-hx of smoking
-BE -3 shows that the body is trying to compensate for respiratory alkalosis. 1. Implement oxygen therapy; titrate O2 to maintain O2 sats greater than or equal to 92%. Use nasal cannula or mask. Per HCP’s orders.
2. Check v/s (pulse oximetry, lung sounds (listen for adventitious sounds) and cardiac and respiratory status at least every 30 minutes) (Ackley & Ladwig, 2014).
3. Diligently monitor RR, depth, and effort, along with signs of distress.
4. Perform physical assessment, document, contact HP if abnormal.
5. Establish patient’s baseline LOC and use it to monitor how interventions are working.
6. Place patient in a semi to high-fowlers position to maximize thoracic expansion and reduce