Write out the patient’s objective & subjective findings that are provided from the case study.  Subjective: Objective

QUESTION

You are a nurse admitting a patient to the hospital from the emergency department (ED) with shortness of breath, weakness, and recent weight loss. The patient has a history of COPD and lung cancer. The patient has not been eating well, and has lost 20 lbs in the past 4 months. The patient’s mobility has been affected not only by her weakness, but also by her worsening shortness of breath. Because of this, the patient has been bed bound for the past few weeks. She also developed a stage 2 pressure ulcer on her coccyx.  The patient is on 2L of O2 per nasal cannula and is only sating at 86% SpO2. Her respiratory rate is 24. The patient has been receiving chemotherapy for the past month for her lung cancer, however she hates how nauseous and weak it makes her feel, so she has decided to stop treatment. The patient also has chronic back pain, and her home pain regimen is proving to no longer be effective at managing her pain. The patient is also very anxious and is intermittently tearful upon assessment.

Write out the patient’s objective & subjective findings that are provided from the case study.

Subjective:

Objective:

Come up with 2 nursing diagnoses for this patient – write out “r/t” and “AEB” statements for each, the best you can.

B. Determine which nursing diagnosis is your top priority for this patient.

For your top rated nursing diagnosis, come up with 1 patient outcome. Make sure this is written utilizing the SMART acronym.

For your identified patient outcome, write out 3 nursing interventions that you would implement to help the patient achieve their goal.

ANSWER

 “Managing Impaired Gas Exchange in a Patient with COPD and Lung Cancer: A Comprehensive Approach to Improve Oxygenation and Respiratory Function”

Subjective Findings

Shortness of breath

Weakness

Recent weight loss (20 lbs in the past 4 months)

Poor appetite

Bed bound for the past few weeks

Stage 2 pressure ulcer on coccyx

Discontinuation of chemotherapy due to nausea and weakness

Chronic back pain

Anxiety and intermittent tearfulness

Objective Findings

Oxygen requirement of 2L per nasal cannula

Oxygen saturation (SpO2) of 86%

Respiratory rate of 24

Nursing Diagnoses

Impaired Gas Exchange r/t COPD and lung cancer AEB oxygen requirement of 2L per nasal cannula, low oxygen saturation (SpO2) of 86%, and respiratory rate of 24.

Imbalanced Nutrition: Less Than Body Requirements r/t poor appetite, recent weight loss (20 lbs in the past 4 months), and discontinuation of chemotherapy AEB objective findings (Kim, 2019).

Top Priority Nursing Diagnosis: Impaired Gas Exchange

Patient Outcome (SMART format): By the end of the next 24 hours, the patient’s oxygen saturation will improve to at least 92% on room air as evidenced by SpO2 readings within the desired range during assessment.

Nursing Interventions

Monitor vital signs and oxygen saturation levels regularly (every 2-4 hours) to assess the patient’s respiratory status and the effectiveness of oxygen therapy (Plüddemann et al., 2011).

Administer supplemental oxygen as prescribed to maintain oxygen saturation levels above 92%. Adjust the oxygen flow rate or delivery method as needed to optimize oxygenation.

Elevate the head of the bed and encourage the patient to perform deep breathing and coughing exercises regularly to promote lung expansion and improve oxygen exchange (Franklin, 2023).

By implementing these interventions, the nurse aims to closely monitor the patient’s respiratory status, ensure adequate oxygenation, and promote optimal lung function to improve the patient’s oxygen saturation. This will help alleviate the symptoms of shortness of breath and weakness, ultimately enhancing the patient’s overall well-being and quality of life.

references

Kim, D. (2019). Nutritional issues in patients with cancer. Intestinal Research, 17(4), 455–462. https://doi.org/10.5217/ir.2019.00076 

Plüddemann, A., Thompson, M., Heneghan, C., & Price, C. (2011). Pulse oximetry in primary care: primary care diagnostic technology update. British Journal of General Practice, 61(586), 358–359. https://doi.org/10.3399/bjgp11x572553 

Franklin, E. (2023, April 27). Incentive Spirometer and Inspiratory Muscle Training. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK572114/