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Terms in this set (66)
,Arthur Alteration in comfort: True
Thomason Alteration in gas exchange:
56-year-old True
MVA victim, Ineffectual airway clearance:
fourth day True
post op with Potential for shock: True
a Prolonged confusion: True
splenectomy Anxiety/fear: True
and femur Potential for failure to thrive:
repair. He is True
experiencing
new onset of
shortness of
breath and
has a nasal
cannula with
2L of Oxygen
in place. He is
restless with
slight
confusion but
is easily
orientated
with attempts
from nurse.
Temperature
spiked during
the night to
102.4, BP now
146/94 which
is slightly
elevated,
respirations at
30 bpm and
slightly
,labored,
heart rate 102
versus 84
from last
night shift.
Skin cool to
touch and
appears pale.
His coughing,
to clear his
airway,
appears
ineffective.
Recent chest
X-ray shows
diffuse
bilateral
interstitial
infiltrates in
all lobes.
Recent blood
gases
demonstrate
falling PaO2
(hypoxemia)
and
increasing
CO2
(Hypercapnia
). Mr.
Thomason is
anxious and is
obviously
worsened
from the shift
, before in
overall
condition.