Abstract
The focus of this paper is to discuss the NANDA-I nursing diagnosis of impaired gas exchange in C.A., a patient admitted to Del Sol Hospital CCU section and was diagnosed with respiratory failure, exacerbation of congestive heart failure, and concentration of bilateral infiltrates in both lungs. Impaired gas exchange occurs when there is an excess or deficit of gas exchange in the lungs. Congestive heart failure causes a decrease in cardiac output and stasis of blood within the lungs resulting in a decrease in perfusion and lung capacity. Additional patient comorbidities exacerbated his condition and contributed to the development of respiratory distress. Expected outcomes for the nursing diagnosis of impaired gas exchange are focused to increase oxygenation and cardiac output and maintaining airway clearance. The criteria needed to determine the effectiveness of the interventions implemented are assessment of cardiac and respiratory status as well as additional laboratory values. The psychosocial assessment of C.A. focused on concepts regarding coping mechanisms, anxiety reduction, completion of developmental stage, holistic care, and family involvement in the care. Assessment of the patient ventilator protocols established by Del Sol Hospital was conducted and compared to the National Security Guidelines for ventilator management.
Keywords: impaired gas exchange, respiratory failure, congestive heart failure
Part I: Discussion of Concepts
Section A: Concept of Impaired Gas Exchange
Gas exchange is the process of exchanging carbon dioxide filled blood for oxygen rich blood at the alveolar capillary membranes. These membranes are ideal for diffusion due to their thin and large surface area that allows for optimal oxygenation. Adequate gas exchange depends on the ventilation-perfusion (V/Q) ratio that measures the amount of air traveling through the alveoli and the amount of blood circulating within the lungs. Impaired gas exchange is an excess or deficit in oxygenation or difficulty in elimination of carbon dioxide at the alveolar-capillary membranes causing an imbalance between the V/Q ratio. (Impaired gas exchange, 2018)
In healthy adults, this gas exchange happens without difficulty; however, there are different diseases that interfere with this process such as chronic obstructive pulmonary disease, asthma, pulmonary edema, heart failure, and pneumonia to name a few. Impaired gas exchange can also occur with physical obstructions such as airway blockages, obesity, prolonged periods of immobility, and excess mucus secretions. As a person ages, there is a decrease in diffusion and pulmonary blood flow. Nursing interventions related to impaired gas exchange include maintaining a patent airway, keeping the trachea midline to the head, positioning, and preventing complications related to the decreases in oxygenation. (Gulanick & Myers, 2014, p. 82)
The patient, C.A., presented with respiratory failure secondary to congestive heart failure exacerbation. Impaired gas exchange is a priority nursing diagnosis due to the nature of his illness. Congestive heart failure (CHF) causes vasoconstriction of the blood vessels which leads to a decrease in cardiac output and impaired gas exchange. Once the cardiac output is affected, it causes an increase in the heart’s workload. This results in further complications, such as left ventricular hypertrophy, resulting in an increase in blood volume residual and pulmonary backflow. As blood continues to backflow into the lungs, fluid accumulates in the space resulting in pulmonary edema. The patient then presents with symptoms of dyspnea, shortness of breath, pulmonary infiltrates, pneumonia, and crackles.
Part II: Individualizing and Integrating Discussion of the Nursing Process with Concepts and Pathophysiology
Section A: The Patient’s Clinical Status
The patient is a 71-year-old Hispanic male who was admitted to CCU on 3/22/18 for respiratory failure secondary to congestive heart failure exacerbation. Upon initial presentation, the patient displayed shortness of breath and oxygen saturation less than 90%. This patient has a past medical history of asthma, CHF, hypertension, dyslipidemia, hypothyroidism, and myocardial infarction (MI). The patient was admitted three weeks prior with the same chief complaint and was treated for community acquired pneumonia as a complication of mechanical ventilation. CHF in those with previously stable heart failure can precipitate exacerbation caused by deteriorating ventricular function (Diaz et al., 2012). Although treatment was similar, the repeat exacerbation and left ventricular ejection fraction of 20-25%, indicated worsening heart failure, and increased pulmonary backflow that contributed to the pulmonary edema and impaired gas exchange.
When respiratory failure occurred, the patient was initially placed on BiPaP; however, he did not tolerate the procedure well and was downgraded to mechanical intubation with Propofol sedation. Because of the patient’s stable respiratory status, he was extubated on 4/4/18 and placed on two liters of oxygen via nasal cannula. The patient also had a nasogastric tube and was receiving continuous enteral feedings of pivot 1.5 calorie strength at 30 milliliters per hour. A 16 French Foley catheter was in place via gravity drainage draining clear, yellow urine with no sediments. Patient initially had a peripheral IV line on the left hand but required replacement due to decreased patency. A new peripheral 20-gauge IV line was placed on 4/5/18 on the left arm with no signs and symptoms of infiltration or infection. The patient was on a Lasix drip of 10 milliliters per hour; however, he displayed signs of dehydration and a potassium level of 2.9 mEq, which required scheduled 300 milliliter water boluses every four hours, discontinuation of Lasix drip, and 20 mEq of potassium chloride via nasogastric tube. Sequential compression devices and fall precautions were in place. The plan of care involved maintaining fluid balance, ensuring adequate gas exchange, and continuing antibiotic treatment.
During observation, the patient’s clinical status dramatically improved with each day. He appeared alert and oriented to person and time with slurred speech and confusion regarding physical limitations. To monitor the patient’s prognosis, daily arterial blood gases, complete metabolic panel and complete blood count labs, and chest x-rays were performed to compare from the previous day. Previously, the chest x-ray displayed bilateral pulmonary infiltrates likely pneumonic in nature and showed improved interstitial edema and/or pneumonia later on. The excessive diuresis led to an increase in BUN at 30 mg/dL and creatinine at 1.1 mg/dL levels, and 2.9 mEq potassium level which led to signs of dehydration. Arterial blood gases show partially compensated metabolic alkalosis with normal oxygenation because of the reabsorption of sodium and secretion of potassium. The patient had an increase heart rate of 150 beats per minute (bpm) that required immediate five milligrams metoprolol IV push, but later normalized to pacemaker setting of 60-70 bpm. After extubation, he required frequent oral suctioning with secretions that were thin, yellow, and of moderate amount eventually progressing to clear thin secretions. Antibiotic treatment for the pulmonary infiltrates included Zosyn 3.375 grams every eight hours IV. Speech therapy ordered a nectar thick fluid and puree diet with one on one feedings and 30 minutes in fowler’s position due to his poor barium swallow evaluation. The patient displayed improved mobility walking ten steps with assistance and improved grip strength by 4/5/18. The long-term goal involved admission to a skilled nursing facility or home health care due to the possibility of further CHF exacerbation and continuation of physical and occupational therapy.
Section B: Priority Nursing Diagnosis
The patient’s clinical status remained critical during observation which warranted frequent monitoring. Taking the mentioned diagnostic and assessment data obtained, the priority nursing diagnoses are listed from highest to lowest priority below.
1. Impaired gas exchange related to pulmonary congestion as evidenced by decreased breath sounds, tachypnea, pH 7.47, paCO2 60, and paO2 90%, and moderate pulmonary secretions.
2. Ineffective airway clearance related to pulmonary congestion as evidenced by decreased breath sounds, tachypnea, bilateral pulmonary infiltrates with moderate amount of secretions, pH 7.47, paCO2 60, and paO2 90%.
3. Decreased cardiac output related to altered myocardial contractility as evidenced by confusion, decreased activity tolerance, left ventricular ejection fraction 20-25%, and blood pressure of 109/57 mm Hg with jugular vein distention.
Section C: Goals and Expected Outcomes
The expected goals and outcomes were patient centered and specific to the diagnosis. Each were tailored to the patient’s capabilities and made to be realistic and measurable. The short and long-term goals are as follows:
1. The patient will have optimal gas exchange as evidenced by:
a. Respiratory rate 12-20 breaths per minute and SpO2 >95% by 4/5/18 at 1400.
b. pH 7.35-7.45, paCO2 35-45 mm Hg, and paO2 > 92% by hospital discharge.
2. The patient will have effective airway clearance as evidenced by:
a. Clear lung sounds in all lung fields by 4/5/18 at 1400.
b. Maintaining a clear and patent airway by hospital discharge.
3. The patient will have adequate cardiac output as evidenced by:
a. Blood pressure of 110-120/60-80 mm Hg and heart rate 60-100 bpm by 4/5/18 at 1400.
b. Warm, dry skin, and +2 bilateral peripheral pulses by hospital discharge
Section D: Interventions
Due to the patient’s high acuity status, multiple components of care were implemented in the treatment plan to best satisfy and meet the goals and outcomes set. According to nursing care plans: diagnoses, interventions, and outcomes (2014), the independent nursing interventions were performed as follows:
1. Determine possible response to compromise by assessing lung sounds, use of accessory muscles, presence of cough, and rate and depth of breathing.
a. Abnormal lung sounds can indicate increased secretions that result in airway compromise. Any changes in respiration can indicate respiratory compromise or dysfunctional mechanical ventilator settings.
2. Note any respiratory obstruction by assessing sputum color, consistency, and amount.
a. Dehydration causes increased thickness of secretions resulting in an increase of airway resistance. Discolored sputum and a moderate to large amount of sputum indicates sign of infection and increased risk of aspiration, respectively.
3. Identify early signs of airway compromise by monitoring heart rate (60-100 bpm), blood pressure (100-120/60-80 mm Hg), respiratory rate (12-20), and SpO2 >95%.
a. A change in respiratory quality, rate, and depth signifies respiratory compromise and obstruction. A decrease in SpO2 indicates low oxygenation that affects tissue perfusion. An increase in work of breathing elevates heart rate and blood pressure.
4. Identify signs of fluid excess by recording intake and output, calculating fluid balance, and auscultating lungs for crackles.
a. Reduced cardiac output results in decreased renal perfusion lowering urine output and retaining fluids to compensate for low blood pressure. Fluids can accumulate in the lungs causing exacerbation of already compromised respiratory function.
5. Prevent aspiration of secretions by performing as needed oral suctioning.
a. Suctioning assists with clearing mucus that may be obstructing the airway. An as needed basis is determined by the patient’s respiratory status and decreases the risk of hypoxia and mucous membrane trauma.
6. Assist with mobilization of secretion by elevating head of bed at least 30 degrees and turning the patient every 2 hours.
a. An upright position promotes lung expansion and improves air exchange while frequent repositioning prevents stasis of secretions and lessens the risk of atelectasis.
In accordance to nursing care plans: diagnoses, interventions, and outcomes (2014), the additional collaborative interventions were implemented as follows:
1. Note changes in acid-base balance by monitoring arterial blood gas (ABG) results according to the following standards: pH 7.35-7.45, paCO2 35-45 mm Hg, and paO2 > 92%.
a. Heart failure decreases pulmonary reserves and causes additional physiological stress resulting in respiratory failure.
2. Understand extent of heart failure by monitoring renal function labs and serum electrolytes such as potassium and sodium levels.
a. A low sodium level is seen in heart failure, which develops into arrhythmias and ECG abnormalities. A low potassium level can be due to excess diuretic use, and an increase in BUN and creatinine can be a result of decreased renal perfusion.
3. Maintain PaO2 >92% by administering two liters of oxygen per nasal cannula and Zosyn 3.375 gram every eight hours IV.
a. Antibiotic therapy aims to treat the patient’s pneumonia responsible for the altered respiratory status. Supplemental oxygen helps maintain oxygen saturation at an adequate level and is at a concentration level that maintains a hypercapnic drive.
4. Decrease fluid volume excess and ensure adequate cardiac output by administering acetazolamide 500 milligrams IV daily, furosemide 40 milligrams IV as directed, diltiazem, and potassium chloride 20 mEq every 6 hours via nasogastric tube.
a. The diuretics help excretes excess fluid volume accumulating, and the potassium chloride ensures adequate potassium levels with diuretic use. The calcium channel blocker decreases blood pressure.
5. Improve oxygenation by encouraging coughing, deep breathing, and splinting the chest.
a. Coughing increases sputum clearance through use of diaphragmatic muscles to ensure effective clearance. Deep breathing promotes deep inspiration, and splinting helps decrease the pain of chest movements by immobilizing the area.
6. Prevent excess oxygen consumption by pacing activities, scheduling rest periods, and reducing anxiety.
a. Paced activities prevent fatigue and the risk of hypoxia. Planning rest periods gives the patient optimal time to regain baseline respiratory rate and depth. Anxiety can cause hyperventilation and increased work of breathing
Section E: Evaluation and Recommendations
Based on a thorough follow up assessment on the dates of the expected outcome, the short term and long-term goals were concluded to be partially met.
1. Expected outcome of adequate gas exchange partially met as evidenced by:
a. Patient respiratory rate at 20 breaths per minute and SpO2 at 100% on two liters oxygen.
b. pH 7.48, pCO2 60 mmHg, paO2 85 mmHg, HCO3 46.8 mmol/L. Dr. Mendez discontinued the Lasix and acetazolamide to reestablish acid base balance and will continue to monitor ABG results to improve outcome.
2. Expected outcome of effective airway clearance partially met as evidenced by:
a. Patient had diminished lung sounds in left lower lobe, but clear throughout other lung fields. The patient will continue on two liters of oxygen via nasal cannula and monitoring of respiratory status to improve outcome.
b. Patient breathing spontaneously with two liters of oxygen via nasal cannula assist and maintained a clear, patent airway.
3. Expected outcome of adequate cardiac output met as evidenced by:
a. Patient’s heart rate at 70 bpm and blood pressure at 116/62 mmHg.
b. Patient was warm to touch, dry, with palpable peripheral pulses + 2 in strength.
Part III: Discussion of Psychosocial Concepts
Patient C.A. is a 71-year-old Hispanic male. Per family, the highest educational level achieved was college. C.A. and his family consider themselves Roman Catholics; they conducted prayers at the patient bedside daily and utilized rosaries and holy water during rituals. Family members expressed concern for C.A. and verbalized feelings of anxiety regarding the patient’s health. The patient’s daughter expressed feelings of stress and anxiety due to frequent absences at work to take care of her father and mother. Anxiety is defined as apprehension, tension, or uneasiness from anticipation of danger, in which the source of anxiety may be unknown or unrecognized (Townsend, 2015). Both the patient’s daughter and the mother were experiencing anxiety due the health condition of the fatherly figure of the household, and under stressful conditions is normal for individuals to resort to coping mechanisms to decrease levels of stress and anxiety. In Latino communities, especially in the elderly, God and religion form an integral part of their lives and are often involved in coping strategies during moments of uncertainty and stress. For older Latinos, God is seen as a partner in their health and lives (Schwingel et al., 2015). For this family, praying to God for the recovery of C.A. helped them cope with the current situation of the patient and promote unity between the family members.
Based on the patient’s age and Erikson's theory of psychosocial development, C.A. is at the stage of Integrity versus Despair. According to Erikson, the final stage of life consists of elderly individuals facing integrity when they accept and embrace their past actions without resentment and are willing to face the present and the future. Individuals in the stage of despair do not feel satisfied with their life, past or present, rejecting anything life has to offer them, prefer isolation, succumb to depression, and fail to thrive, which often leads to their death (Fowler, 2016). In the integrity stage, the patient feels satisfied with his life, has no regrets about his past, and feels grateful. Family members verbalized that C.A. had lived a purposeful life with pride and embraced both good and bad decisions taken during his life. According to family members, C.A. prefers to share his life in company of friends and family, and is grateful to God about the gift of life. It is worth noting that C.A. was receiving constant support from his family during his hospital stay, and this factor was pivotal to assist with the recovery of the patient. C.A. recovery appeared to thrive under the presence of family members, and this was demonstrated during the second day of clinicals, where the patient was already extubated and was able to walk up to ten steps away from his bed. Due to the patient’s history of asthma and heart disease, physical activity was restricted, but this has not deterred the patient from engaging in moderate physical activity and abstaining from drinking. The family members verbalized that C.A. enjoys playing musical instruments during his free time.
Although the patient was intubated for a short period during the first day of clinical, was fed via NG tube, and was not able to walk or conduct ADLs independently, by the second day of clinicals, the patient was extubated and was able to walk ten steps with assistance. The patient’s demeanor remained calm, and projected positivism about the future. C.A.’s positive attitude in the face of adversity comes because of accepting his current health situation and understanding that he lived a fulfilling life with pride around his beloved ones, increasing his sense of wholesomeness. Studies done in past years correlate high levels of integrity in the individual with higher levels of wellbeing regardless of their current health situation (Dezutter et al., 2013). C.A. higher level of spirituality helps him feel reassured that God will take care of him and his family and helps to ease feelings about the uncertainty of death to the patient and his family members. Previous studies have positively correlated the frequency of spirituality with increased thoughts about God, transcendence and security, and decreased concerns about death (Park et al, 2013).
Family members have been active participants in the care of C.A. Initially, they were in denial about the possibility of having to transfer C.A to hospice care or what to do in case of the death of the patient. Further inquiring revealed that the patient also had not discussed the possibility of death with family members. After extubating the patient, the family decided to change the patient resuscitation status to do not resuscitate and are contemplating to allocate C.A. into hospice care when the need arises. The patient and family members are aware that the recovery process of CHF exacerbation and pneumonia will be long and understand and accept that the patient lifestyle and activity will not revert to pre-hospitalization status.
Part IV: Discussion of National Practice Guideline
Patient C.A. required ventilator use due to respiratory failure secondary to CHF exacerbation. Prior to the clinical visit, the patient had already been admitted and ventilated for a week. Some of the complications of invasive mechanical ventilation are barotrauma, impaired gas exchange and patient discomfort. To prevent further complications brought on by prolong use of the ventilator, spontaneous breathing trials were conducted on the patient once respiratory status was considered adequate. Before extubating a patient, “a 30-min spontaneous breathing trial (SBT) should be used to assess suitability for extubating” (Davidson, et al., 2016). During the trial and after extubation, the patient’s heart rate must be below 140, respiration should be less than 35 with no sign of distress such as nasal flaring or use of accessory muscles, and oxygen saturation must be greater than 90%. The hospital implemented this guideline through careful titration of propofol sedation and admission to a critical care unit with continuous cardiac and oxygenation monitoring. The patient met these guidelines and displayed no further drastic complications as evidenced by a heart rate of 70 bpm, respiratory rate of 20 with no use of nasal flaring or accessory muscles, and an oxygen saturation of 100%. After extubating the patient, he displayed thick, yellow secretions that were moderate in amount. Per Davidson (2016), heated humidification should be considered if there is mucosal dryness or thick secretions. The hospital humidified the oxygen when the patient was ventilated and extubated with two liters of oxygen via nasal cannula to decrease the amount and viscosity of the secretions. Because sputum retention is a precipitant to nosocomial infections such as ventilator associated pneumonia, it is recommended that sputum clearance be promoted (Davidson, 2016). Despite the patient’s weak musculature, he could perform coughing exercises, frequent position changes, and ambulating to decrease stasis and promote excretion of the sputum. If the patient was unable to do so, oral suctioning was completed by the nurse on an as needed basis in addition to frequent oral care every two hours.
In conclusion, Del Sol Medical Center did an excellent job when preventing ventilator associated complications. They followed ngc.gov guidelines and implemented them within their hospital protocols. When extubation is performed as soon as adequate respiratory status permits and sputum retention is reduced, the patient’s outcome was increased and further improved the patient’s health status for the better.