Question 1.
A. AIRWAY– Maintaining a clear airway is always considered a high priority because the airway is essential for gas exchange. However, the patient has a patent airway (Ramkumar, 2011).
The nursing strategy is to conduct an airway assessment “look, listen and feel” continuously to detect any changes. This is to provide immediate respiratory care if the patient’s airway is compromised (Higginson, Jones & Davies, 2011). This is a low priority.
B. BREATHING – Respiration is altered due to left ventricular failure. The patient is tachypnoeic due to an increased pressure in the pulmonary veins that will lead to pulmonary congestion that lessens pulmonary compliance, which raises the respiratory rate. Also, increased blood flow in the …show more content…
This will promote chest expansion and reduced the workload of the heart. Early detection of respiratory distress will assist in emergency interventions and reduce the risk of complications (Jaffe & Cabrera, 2016). This is considered a high …show more content…
The PaO2 is low because less oxygen is dissolved in the blood and signifies hypoxemia. The PaCO2 is normal, which means the amount of carbon dioxide gas dissolved in the blood is adequate and represents the effectiveness of ventilation. This is evident by increased respiratory rate of the patient. A low HCO3 indicates acidosis in the metabolic component. The base excess is higher than the normal range, which suggests a metabolic cause. An elevated lactate indicates lactic acidosis as a result of tissue hypoxia as evidence by decreased in systemic blood flows (Ringdal & Gullick, 2015). Therefore, the patient has metabolic acidosis due to an injury to the myocardium that caused a decreased in cardiac output, tissue hypoxia, and low bicarbonate due to rise in lactic acid Also, it is uncompensated as per the PaCO2 is normal (Gandhi & Akholkar,
A. AIRWAY– Maintaining a clear airway is always considered a high priority because the airway is essential for gas exchange. However, the patient has a patent airway (Ramkumar, 2011).
The nursing strategy is to conduct an airway assessment “look, listen and feel” continuously to detect any changes. This is to provide immediate respiratory care if the patient’s airway is compromised (Higginson, Jones & Davies, 2011). This is a low priority.
B. BREATHING – Respiration is altered due to left ventricular failure. The patient is tachypnoeic due to an increased pressure in the pulmonary veins that will lead to pulmonary congestion that lessens pulmonary compliance, which raises the respiratory rate. Also, increased blood flow in the …show more content…
This will promote chest expansion and reduced the workload of the heart. Early detection of respiratory distress will assist in emergency interventions and reduce the risk of complications (Jaffe & Cabrera, 2016). This is considered a high …show more content…
The PaO2 is low because less oxygen is dissolved in the blood and signifies hypoxemia. The PaCO2 is normal, which means the amount of carbon dioxide gas dissolved in the blood is adequate and represents the effectiveness of ventilation. This is evident by increased respiratory rate of the patient. A low HCO3 indicates acidosis in the metabolic component. The base excess is higher than the normal range, which suggests a metabolic cause. An elevated lactate indicates lactic acidosis as a result of tissue hypoxia as evidence by decreased in systemic blood flows (Ringdal & Gullick, 2015). Therefore, the patient has metabolic acidosis due to an injury to the myocardium that caused a decreased in cardiac output, tissue hypoxia, and low bicarbonate due to rise in lactic acid Also, it is uncompensated as per the PaCO2 is normal (Gandhi & Akholkar,