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Priority Nursing Problem (Analysis): Impaired gas exchange, Nursing…

- - - - Administer prescribed medications that improve gas exchange. This includes bronchodilators, steroids, and pain medications for chest discomfort. Bronchodilators help to open the airways and allow for more productive breathing. Steroids reduce any inflammation that could be occuring within the lungs.
        
        Keep patient in an elevated position or head of bed raised 30 degrees. This position allows for optimal lung expansion and ventilation. It also helps the diaphragm to properly contract and relieves any pressure on the chest. By maintaining any elevated position, this can help improve SpO2 levels and decrease CO2 levels.
  - - - Patient will show less signs of hypoxia. Nurse will monitor patient's skin tone to watch for return of normal color. Patient will no longer have pale/blue skin tone. Patient's capillary refill time will be less than 3 seconds. Patient will no longer show signs of confusion. Nurse will ensure patient is receiving the correct amount of supplemental oxygen to achieve goal and perform ADLs.
    - - Patient needs assistance with medications. Nurse will provide patient with prescribed medications daily/time of administration. Patient receives 26 medications that supplement/aid in a variety of ways. Many of the medications aid proper oxygenation and prevent respiratory distress. Nurse will ensure patient takes all the medications at the proper time in the proper administration manner.
        
        Patient needs assistance with portable oxygen. Safety checks/ensuring that O2 is on correctly should occur every 2 hours starting at 0000. PRN oxygen checks should also occur. Nurse should assess for any signs of hypoxia, such as confusion and pale/blue skin color. Nurse should also assess for any medical device pressure ulcers that cause occur around the nose due to nasal cannula,
        
        Patient needs help completing ADLs. Patient needs assistance with laundry once a week. Patient needs assistance with bathing/showering daily. Patient needs assistance with dressing daily. Since patient has some limits on mobility, nurse/staff should ensure patient is able to move about tiger place and is getting proper nutrition.
        
        Patient's vital signs are to be checked every month (day 5 at 1600). However, vital signs can be checked more frequently to ensure patient has stable oxygen saturation, breath sounds/respiration rate, heart rate, blood pressure, temperature, and pain. Nurse should ensure patient is not displaying any signs of labored breathing while assessing vitals. Vitals can indicate poor oxygen exchange as well as nasal flaring, tripod position, or frequent coughing.