Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 2 Respiratory System^121



  • Confusion and restlessness due to hypoxemia

  • Irritability due to hypoxemia


INTERPRETING TEST RESULTS



  • Carbon dioxide (CO 2 ) >50 mmHg shown in arterial blood gas

  • pH of blood < 7.35 shows acidosis in arterial blood gas


TREATMENT


Treatment is focused on restoring appropriate ventilation, returning carbon diox-
ide levels to normal, and returning pH levels to normal.



  • Give supplemental oxygen, monitoring flow rate to avoid excess oxygen to
    those who have chronic pulmonary conditions. The chronic nature of the res-
    piratory acidosis in these patients may have caused the internal respiratory
    control to adjust in response to a decrease in oxygen level rather than an
    increase in carbon dioxide level, which is always higher than normal.

  • Administer bronchodilators to open constricted airways:

    • albuterol, metaproterenol, levalbuterol



  • Administer medications as necessary to correct underlying disorder.

  • Administer antibiotics as ordered as a result of the sensitivity test.

  • Mechanical ventilation if necessary to support breathing.

  • Treat underlying cause.


NURSING DIAGNOSES



  • Ineffective breathing

  • Fear

  • Impaired gas exchange


NURSING INTERVENTION



  • Monitor respiration for rate, effort, use of accessory muscles, skin color,
    mucous production, and breath sounds.

  • Monitor blood chemistry—potassium, CO 2 , chloride

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