Respiratory Acidosis Nursing Care Plan

Respiratory Acidosis Nursing Care Plan Impaired Gas Exchange May be related to Ventilation perfusion imbalance (altered oxygen-carrying capacity ofblood, altered oxygen supply, alveolar-capillary membrane changes, or altered blood flow) Possibly evidenced by Dyspnea with exertion, tachypnea Changes in mentation, irritability  Tachycardia  Hypoxia, hypercapnia Desired Outcomes      Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced byABGswithin patient’s acceptable limits and absence of symptoms of respiratory distress. Verbalize understanding of causative factors and appropriate interventions. Participate in treatment regimen within level of ability/situation. Nursing Interventions Rationale Monitor respiratory rate, depth, and effort. Alveolar hypoventilation and associated hypoxemia lead to respirator distress or failure. Auscultate breath sounds. Identifies areas of decreased ventilation (atelectasis) or airway obstru and changes as patient deteriorates or improves, reflecting effectiven treatment, dictating therapy needs. Nursing Interventions Rationale Note declining level of consciousness. Signals severe acidotic state, which requires immediate attention. Not recovery, sensorium clears slowly because hydrogen ions are slow to c the blood-brain barrier and clear from cerebrospinal fluid and brain ce Monitor heart rate and rhythm. Tachycardia develops early because the sympathetic nervous system i stimulated, resulting in the release of catecholamines, epinephrine, a norepinephrine, in an attempt to increase oxygen delivery to the tissu Dysrhythmias that may occur are due to hypoxia (myocardial ischemia electrolyte imbalances. Note skin color, temperature, moisture. Diaphoresis, pallor, cool or clammy skin are late changes associated w severe or advancing hypoxemia. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position. These measures improve lung ventilation and reduce or prevent airwa obstruction associated with accumulation of mucus. Restrict use of hypnotic sedatives or tranquilizers. In the presence of hypoventilation, respiratory depression and CO2 na may develop. Discuss cause of chronic condition (when known) and appropriate interventions and selfcare activities. Promotes participation in therapeutic regimen, and may reduce recur of disorder. Assist with identification or treatment of underlying cause. Treatment of disorder is directed at improving alveolar ventilation. Addressing the primary condition (oversedation, lung and respiratory system trauma, pulmonary edema, aspiration) promotes correction of acid-base disorder. Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels. Evaluates therapy need and effectiveness. Note: Bedside pulse oximet monitoring is used to show early changes in oxygenation before other Nursing Interventions Rationale or symptoms are observed. Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used. Prevents and corrects hypoxemia and respiratory failure. Note: Must used with caution in presence of emphysema because respiratory depression or failure may result. Assist with ventilatory aids: IPPB in conjunction with bronchodilators. Monitor peak flow pressure. Increases lung expansion and opens airways to improve ventilation, preventing respiratory failure. Maintain hydration (IV/PO) and provide humidification. Assists in correction of acidity and thinning and mobilization of respira secretions. Provide appropriate chest physiotherapy, including postural drainage and breathing exercises. Aids in clearing secretions, which improves ventilation, allowing exces CO2 to be eliminated. Administer IV solutions such as lactated Ringer’s solution or 0.6 M solution of sodium lactate. May be useful in nonemergency situations to help control acidosis, un underlying respiratory problem can be corrected. Administer medications as indicated: Naloxone hydrochloride (Narcan) May be useful in arousing patient and stimulating respiratory function presence of drug overdose and sedation, or acidosis resulting from ca arrest. Sodium bicarbonate (NaHCO3) May be given in small IV doses in emergency situations to quickly corr acidosis if pH is less than 7.25 and hyperkalemia coexists. Note: Rebou alkalosis or tetany may occur. Nursing Interventions Rationale Potassium chloride (KCl) Replaces potassium that shifts out of cells during acidotic state. Corre of the acidosis may cause a relative serum hypokalemia as potassium back into cells. Potassium imbalance can impair neuromuscular or respiratory function, causing generalized muscle weakness and cardia dysrhythmias. Bronchodilators Helps open constricted airways to improve gas exchange. Provide low-carbohydrate, high-fat diet (Pulmocare feedings), if indicated. Helps reduce CO2 production and improves respiratory muscle functio metabolic homeostasis.