Case Study Acute Respiratory Failure

Acute Respiratory Failure This case study of 211A will contain the basic conditioning factors, expected signs and symptoms of primary medical diagnosis, nursing diagnosis, plan of care, the medications, and the overall expectation of 211A.

BASIC CONDITIONIG FACTORS 211A is a 63year old female who was admitted to Providence Little Company of Mary sub-acute unit on September 30,2016. The admitting diagnosis was Acute Respiratory Failure, Cardio Vascular Accident, and Pneumonia. She has a history of Intracranial hemorrhage, Acute Encephalopathy, Hepatocellular, Urinary Tract Infection, Anemia, Gastroesophageal Reflux Disease, Seizures, and Contractures. 211A is alert and oriented to name, place, and date of birth. Her primary language is English

(Leonard Hudson, Arthur Slushy). Respiratory Failure happens when tiny blood vessels surrounding the alveoli can not properly exchange carbon dioxide for oxygen. When observing a patient in Acute Respiratory Failure you will see restlessness, anxiety, sleepiness, loss of consciousness, rapid and shallow breathing, heart racing, arrhythmias, and profuse sweating. Some diagnostic test that are performed are capnography which is the monitoring of carbon dioxide, a sputum culture to identify bacteria in the lungs that maybe affecting the breathing, a chest x ray to determine if there are any respiratory problems, checking Pao2 and PaCO2 labs for impaired gas exchange, and oxygen saturation to measure the oxygen in the blood.

NURSING DIAGNOSIS According to Ackley and Ladwig (2011), the prioritized nursing diagnosis for 211A "Risk for ineffective airway Clearance" (p.180) related to increased secretions secondary to tracheostomy as evidence by suctioning secretions two times per shift. The goal of nursing care for 211A would be to maintain a clear and open airway during shift. Impaired Gas Exchange related to alveolar- capillary membrane changes secondary to hypercapnia as evidence by abnormal breathing (p.394). The goal is to maintain clear lungs and free from signs of respiratory

Administer breathing treatment as needed. Suctioning as needed checking the color, and amount. Elevating head of bed to 30-45 degrees. I would also monitor oxygen saturation making sure that it does fall below 93%. Maintain skin integrity by turning patient every two hours, no cresses in the sheets, monitoring incontinence by changing brief when wet and making sure perineal area is clean and dry. Apply a barrier ointment during changes. Always using personal protective equipment when entering into the room to prevent infection. Provide proper hand washing before, in between, and after care to prevent the spread of infection. Make sure the bed is always lowered, side rails up and call light within reach to promote