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Impaired spontaneous ventilation r/t immersion syndrome (Assesment: (pH: 7…
Impaired spontaneous ventilation r/t immersion syndrome
Assesment:
Pulse: 45
temperature: 32.6 C (90.7 F)
SpO2 = 75%
RR --> apneic
pH: 7.29 (acidic) and PaCO2: 70 (high)
indicating respiratory acidosis
Goal 1:
Patient will effectively mobilize secretions throughout hospital stay.
Intervention 1:
"Nurse will position the client in a semicumbent with the head of the bed at 30-45 degree angle to decrease the aspiration of gastric, oral and nasal secretions" (Ackley, Ladwig, & Makic, 843).
Rationale:
Historically, evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30-45 degree angle as opposed to supine position.
Intervention 2:
Nurse will use endotracheal tubes that allow for the continuous aspiration of subglottic secretions (Ackley, Ladwig, & Makic, 843).
Rationale:
Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late onset VAP.
Goal 2:
Patient will maintain an oxygen saturation of above 70% throughout hospital stay.
Intervention 2:
Nurse will analyze and respond to arterial blood gas results, end tidal CO2 levels, and pulse oximetry values.
Rationale:
Ventilatory support must be closely monitored to ensure adequate oxygenation and acid-base balance.
Intervention 1:
Nurse will ensure that ventilator are appropriate to meet the client's minute ventilation requirements (Ackley, Ladwig, & Makic, 841).
Rationale:
Ventilator setting should be adjusted to prevent hyperventilation or hypo-ventilation . A variety of new modes of ventilation are currently available that are responsive to patient effort.
Goal 1/ Outcome evaluation:
met goal and was able to mobilize secretions, continue plan.
Goal 2/ Outcome Evaluation:
Patient maintained an O2 sat. above 70% throughout hospital stay, continue plan as is. Goal met.