Nursing Care Plans Diagnosis: Impaired Oral mucous membrane

Definition: Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics: Purulent drainage or exudates; gingival recession, pockets deeper than 4 mm; enlarged
tonsils beyond what is developmentally appropriate; smooth atrophic, sensitive tongue; geographic tongue; mucosal
denudation; presence of pathogens; difficult speech; self-report of bad taste; gingival or mucosal pallor; oral
pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules; white patches/plaques, spongy patches, or white
curd-like exudate; oral lesions or ulcers; halitosis; edema; hyperemia; desquamation; coated tongue; stomatitis; self-
report of difficult eating or swallowing; self-report of diminished or absent taste; bleeding; macroplasia; gingival
. hyperplasia; fissures, cheilitis; red or bluish masses

Related Factors: Chemotherapy; chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); depression;
immunosuppression; aging-related loss of connective, adipose, or bone tissue; barriers to professional care; cleft lip or
palate; medication side effects; lack of or decreased salivation; chemical trauma (e.g., acidicfoods , drugs, noxious
agents, alcohol); pathological conditions—oral cavity (radiation to head or neck); NPO for more than 24 hours; mouth
breathing; malnutrition or vitamin deficiency; dehydration; infection; ineffective oral hygiene; mechanical (e.g., ill-
fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); decreased platelets;
immunocompromised; impaired salivation; radiation therapy; barriers to oral self-care; diminished hormone levels
(women); stress; loss of supportive structures

(NOC Outcomes (Nursing Outcomes Classification

Suggested NOC Labels
Oral Health •
Tissue Integrity: Skin and Mucous Membranes •
Client Outcomes
Maintains intact, moist oral mucous membranes that are free of ulceration and debris •
Describes or demonstrates measures to regain or maintain intact oral mucous membranes •
(NIC Interventions (Nursing Interventions Classification
Suggested NIC Labels
Oral Health Restoration •

Nursing Interventions and Rationales

Inspect oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer •
to a physician or specialist as appropriate. Oral inspection can reveal signs of oral disease, symptoms of systemic
.disease, drug side effects, or trauma of the oral cavity
Assess for mechanical agents such as ill-fitting dentures or chemical agents such as frequent exposure to tobacco that •
could cause or increase trauma to oral mucous membranes. Irritative and causative agents for stomatitis should be
. eliminated
Monitor client's nutritional and fluid status to determine if adequate. Refer to the care plan for Deficient Fluid volume •
or Imbalanced Nutrition: less than body requirements if applicable. Dehydration and malnutrition predispose clients to
.impaired oral mucous membranes
Encourage fluid intake up to 3000 ml per day if not contraindicated by client's medical condition (Rhodes, McDaniel, •
Johnson, 1995). Fluids help increase moisture in the mouth, which protects the mucous membranes from damage and
.helps the healing process
Determine client's mental status. If client is unable to care for self, oral hygiene must be provided by nursing •
.personnel. Thenursing diagnosis Bathing/Hygiene Self-care deficit is then also applicable
Determine client's usual method of oral care and address any concerns regarding oral hygiene. Whenever possible, •
.build on client's existing knowledge base and current practices to develop an individualized plan of care
If client does not have a bleeding disorder and is able to swallow, encourage to brush teeth with a soft pediatric-sized •
toothbrush using a fluoride-containing toothpaste after every meal and to floss teeth daily. The toothbrush is the most
important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling
 .periodontal disease
Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or •
hydrogen peroxide. Also, do not use lemon-glycerin swabs. Alcohol dries the oral mucous membranes Hydrogen
peroxide can damage oral mucosa and is extremely foul tasting to clients (Tombes, Gallucci, 1993; Winslow, 1994).
.Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel
Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous •
client. Do not use to clean the teeth or else the platelet count is very low, and the client is prone to bleeding gums.
Studies have shown that foam sticks are probably not effective for removing plaque from teeth. However, they are
.useful for cleaning the mouth of the edentulous client
If client's oral cavity is dry, the keep inside of the mouth moist with frequent sips of water and salt water rinses (1/2 tsp •
salt in 8 oz of warm water) or artificial saliva. Moisture promotes the cleansing effect of saliva and helps avert mucosal
drying, which can result in erosions, fissures, or lesions. Sodium chloride rinses have been shown to be effective for the
.prevention and treatment of stomatitis
. Keep lips well lubricated using petroleum jelly or a similar product •
For clients with stomatitis, increase frequency of oral care up to every hour while awake if necessary. Increasing the •
.frequency of oral care has been shown to be effectively decrease stomatitis
Provide scrupulous oral care to critically ill clients. Cultures of the teeth of critically ill clients have yielded significant •
.bacterial colonization, which can cause nosocomial pneumonia
If mouth is severely inflamed and it is painful to swallow, contact the physician for a topical anesthetic agent or •
analgesic order. Modification of oral intake (e.g., soft or liquid diet) may also be necessary to prevent friction trauma.
.Thenursing diagnosis Imbalanced Nutrition: less than body requirements may apply
If whitish plaques are present in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red •
base that bleeds, suspect a fungal infection and contact the physician for follow-up. Oral candidiasis (moniliasis) is
extremely common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive
.drugs and should be treated with oral or systemic antifungal agents
.If client is unable to swallow, keep suction nearby when providing oral care •
.Refer to Impaired Dentition if the client has problems with the teeth •
Geriatric
Carefully observe oral cavity and lips for abnormal lesions such as white or red patches, masses, ulcerations with an •
indurated margin, or a raised granular lesion. Malignant lesions are more common in elderly persons than in younger
.persons (especially if there is a history of smoking or alcohol use), and many elderly persons rarely visit a dentist
Ensure that dentures are removed and scrubbed at least once daily, removed and rinsed thoroughly after every meal, •
and removed and kept in an appropriate solution at night. This is an evidence-based protocol for denture care. Denture
plaque-containing candidiasis can cause denture-induced stomatitis, which is more common with unhealthy lifestyles
. and poor oral hygiene than otherwise
Home health Care Interventions
Instruct client to avoid alcohol- or hydrogen peroxide-based commercial products for mouth care and to avoid other •
irritants to the oral cavity (e.g., tobacco, spicyfoods). Oral irritants can further damage the oral mucosa and increase the
.client's discomfort
.Instruct client in ways to soothe the oral cavity •
.If client often breathes by mouth, add humidity to room unless contraindicated •
.If necessary, refer for home health aide services to support family in oral care and observation of the oral cavity •
Client/Family Teaching
Teach client how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and •
.healing
Teach how to implement a personal plan of oral hygiene including a schedule of care. Encouragement and •
.reinforcement of oral care are important to oral outcomes

Top of Form

Nursing Diagnosis: Ineffective airway clearance

(NOC Outcomes (Nursing Outcomes Classification
 Suggested NOC Labels

Respiratory Status: Airway Patency •

(NIC Interventions (Nursing Interventions Classification
Suggested NIC Labels

Cough Enhancement •

Airway Management •

Airway Suctioning •
NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the
cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/
trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles
and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as
anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased
production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective
airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or
spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of
.chronic cough or sputum production, are at high risk
:Defining Characteristics
(Abnormal breath sounds (crackles, rhonchi, wheezes•
Changes in respiratory rate or depth•
Cough•
Hypoxemia/cyanosis•
Dyspnea•
Chest wheezing•
Fever•
Tachycardia•
:Related Factors
Decreased energy and fatigue•
Ineffective cough•
Tracheobronchial infection•
(Tracheobronchial obstruction (including foreign body aspiration•
Copious tracheobronchial secretions•
Perceptual/cognitive impairment•
Impaired respiratory muscle function•
Trauma•
Expected Outcomes
Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds,•
.eupnea, and ability to effectively cough up secretions after treatments and deep breaths

Ongoing Assessment

Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, •
.acute neurological decompensation, or cardiac arrest

:Auscultate lungs for presence of normal or adventitious breath sounds, as in the following •
Decreased or absent breath sounds These may indicate presence of mucus plug or other major airway ○
.obstruction
.Wheezing These may indicate increasing airway resistance ○
.Coarse sounds These may indicate presence of fluid along larger airways ○

Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of •
.splinting, use of accessory muscles, and position for breathing. Abnormality indicates respiratory compromise

Assess changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be early •
.signs of cerebral hypoxia

Assess changes in vital signs and temperature. Tachycardia and hypertension may be related to increased •
.work of breathing. Fever may develop in response to retained secretions/atelectasis

Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough (e.g., •
.(respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions

Note presence of sputum; assess quality, color, amount, odor, and consistency. This may be a result of •
infection, bronchitis, chronic smoking, or other condition. A sign of infection is discolored sputum (no longer
.clear or white); an odor may be present

Send a sputum specimen for culture and sensitivity as appropriate. Respiratory infections increase the work of
.breathing; antibiotic treatment is indicated

Monitor arterial blood gases (ABGs). Increasing PaCO2 and decreasing PaO2 are signs of respiratory •
.failure

.Assess for pain. Postoperative pain can result in shallow breathing and an ineffective cough •

If patient is on mechanical ventilation, monitor for peak airway pressures and airway resistance. Increases in •
.these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation

Assess patient’s knowledge of disease process. Patient education will vary depending on the acute or •
.chronic disease state as well as the patient’s cognitive level
 Therapeutic Interventions

.Assist patient in performing coughing and breathing maneuvers. These improve productivity of the cough •

:Instruct patient in the following •

(Optimal positioning (sitting position○
Use of pillow or hand splints when coughing○
Use of abdominal muscles for more forceful cough○
Use of quad and huff techniques○
Use of incentive spirometry○
Importance of ambulation and frequent position changes○
Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the
coughing is done at varying times. The sitting position and splinting the abdomen promote more effective
.coughing by increasing abdominal pressure and upward diaphragmatic movement

Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation). These promote better •
.lung expansion and improved air exchange

If patient is bedridden, routinely check the patient’s position so he or she does not slide down in bed. This •
.may cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment

:If cough is ineffective, use nasotracheal suctioning as needed •

.Explain procedure to patient○
.Use soft rubber catheters. This prevents trauma to mucous membranes ○
Use curved-tip catheters and head positioning (if not contraindicated). These facilitate secretion removal ○
.(from a specific side (right versus left lung
Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure○
.and use supplemental oxygen as appropriate. This prevents suction-related hypoxia
Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient○
.experiences bradycardia, an increase in ventricular ectopy, and/or desaturation
Use universal precautions: gloves, goggles, and mask as appropriate. If sputum is purulent, precautions ○
.should be instituted before receiving the culture and sensitivity report
Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of
.weakness, thick mucus plugs, or excessive mucus production

Institute appropriate isolation precautions for positive cultures (e.g., methicillin-resistant Staphylococcus •
.(aureus [MRSA] or tuberculosis

.Use humidity (humidified oxygen or humidifier at bedside). This loosens secretions •

 Encourage oral intake of fluids within the limits of cardiac reserve. Increased fluid intake reduces the •
viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner
.secretions with coughing

Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered, noting •
.effectiveness and side effects

For patients with chronic problems with bronchoconstriction, instruct in use of metered-dose inhaler (MDI) •
.or nebulizer as prescribed

Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and •
home care/rehabilitation environments). Chest physiotherapy includes the techniques of postural drainage and
.chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning

Coordinate optimal time for postural drainage and percussion (i.e., at least 1 hour after eating). This prevents
.aspiration

For patients with reduced energy, pace activities. Maintain planned rest periods. Promote energy- •
.conservation techniques. Fatigue is a contributing factor to ineffective coughing

For acute problem, assist with bronchoscopy. This obtains lavage samples for culture and sensitivity, and •
.removes mucus plugs

:If secretions cannot be cleared, anticipate the need for an artificial airway (intubation). After intubation •
.Institute suctioning of airway as determined by presence of adventitious sounds○
.Use sterile saline instillations during suctioning. This helps facilitate removal of tenacious sputum ○

.For patients with complete airway obstruction, institute cardiopulmonary resuscitation (CPR) maneuvers •
Education/Continuity of Care

Demonstrate and teach coughing, deep breathing, and splinting techniques. Patient will understand the •
.rationale and appropriate techniques to keep the airway clear of secretions

.Instruct patient on indications for, frequency, and side effects of medications •

.Instruct patient how to use prescribed inhalers, as appropriate •

.In home setting, instruct caregivers regarding cough enhancement techniques and need for humidification •

Instruct caregivers in suctioning techniques. Provide opportunity for return demonstration. Adapt technique •
.for home setting
For patients with debilitating disease being cared for at home (CVA, neuromuscular impairment, and others), •
instruct caregiver in chest physiotherapy as appropriate. This may also be useful for the patient with
bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the
.inability to adequately clear them

.Teach patient about environmental factors that can precipitate respiratory problems •

Explain effects of smoking, including second-hand smoke. Smoking contributes to bronchospasm and •
.increased mucus production in the airways

Refer patient and/or significant others to smoking-cessation group, as appropriate, and discuss potential use •
.of smoking-cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to wean off the effects of nicotine

.Instruct patient on warning signs of pending or recurring pulmonary problems •

.Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated •

Top of Form

Nursing Diagnosis: Ineffective airway clearance

(NOC Outcomes (Nursing Outcomes Classification
Suggested NOC Labels

Respiratory Status: Airway Patency •

(NIC Interventions (Nursing Interventions Classification
Suggested NIC Labels

Cough Enhancement •

Airway Management •

Airway Suctioning •
NANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency
Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the
cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/
trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles
and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as
anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased
production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective
airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or
spinal cord injury) problem. Elderly patients, who have an increased incidence of emphysema and a higher prevalence of
.chronic cough or sputum production, are at high risk
 :Defining Characteristics
(Abnormal breath sounds (crackles, rhonchi, wheezes•
Changes in respiratory rate or depth•
Cough•
Hypoxemia/cyanosis•
Dyspnea•
Chest wheezing•
Fever•
Tachycardia•
:Related Factors
Decreased energy and fatigue•
Ineffective cough•
Tracheobronchial infection•
(Tracheobronchial obstruction (including foreign body aspiration•
Copious tracheobronchial secretions•
Perceptual/cognitive impairment•
Impaired respiratory muscle function•
Trauma•
Expected Outcomes
Patient's secretions are mobilized and airway is maintained free of secretions, as evidenced by clear lung sounds,•
.eupnea, and ability to effectively cough up secretions after treatments and deep breaths

Ongoing Assessment

Assess airway for patency. Maintaining the airway is always the first priority, especially in cases of trauma, •
.acute neurological decompensation, or cardiac arrest

:Auscultate lungs for presence of normal or adventitious breath sounds, as in the following •
Decreased or absent breath sounds These may indicate presence of mucus plug or other major airway ○
.obstruction
.Wheezing These may indicate increasing airway resistance ○
.Coarse sounds These may indicate presence of fluid along larger airways ○

Assess respirations; note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of •
.splinting, use of accessory muscles, and position for breathing. Abnormality indicates respiratory compromise

Assess changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be early •
.signs of cerebral hypoxia
 Assess changes in vital signs and temperature. Tachycardia and hypertension may be related to increased •
.work of breathing. Fever may develop in response to retained secretions/atelectasis

Assess cough for effectiveness and productivity. Consider possible causes for ineffective cough (e.g., •
.(respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions

Note presence of sputum; assess quality, color, amount, odor, and consistency. This may be a result of •
infection, bronchitis, chronic smoking, or other condition. A sign of infection is discolored sputum (no longer
.clear or white); an odor may be present

Send a sputum specimen for culture and sensitivity as appropriate. Respiratory infections increase the work of
.breathing; antibiotic treatment is indicated

Monitor arterial blood gases (ABGs). Increasing PaCO2 and decreasing PaO2 are signs of respiratory •
.failure

.Assess for pain. Postoperative pain can result in shallow breathing and an ineffective cough •

If patient is on mechanical ventilation, monitor for peak airway pressures and airway resistance. Increases in •
.these parameters signal accumulation of secretions/ fluid and possibility for ineffective ventilation

Assess patient’s knowledge of disease process. Patient education will vary depending on the acute or •
.chronic disease state as well as the patient’s cognitive level
Therapeutic Interventions

.Assist patient in performing coughing and breathing maneuvers. These improve productivity of the cough •

:Instruct patient in the following •

(Optimal positioning (sitting position○
Use of pillow or hand splints when coughing○
Use of abdominal muscles for more forceful cough○
Use of quad and huff techniques○
Use of incentive spirometry○
Importance of ambulation and frequent position changes○
Directed coughing techniques help mobilize secretions from smaller airways to larger airways because the
coughing is done at varying times. The sitting position and splinting the abdomen promote more effective
.coughing by increasing abdominal pressure and upward diaphragmatic movement

Use positioning (if tolerated, head of bed at 45 degrees; sitting in chair, ambulation). These promote better •
.lung expansion and improved air exchange
 If patient is bedridden, routinely check the patient’s position so he or she does not slide down in bed. This •
.may cause the abdomen to compress the diaphragm, which would cause respiratory embarrassment

:If cough is ineffective, use nasotracheal suctioning as needed •

.Explain procedure to patient○
.Use soft rubber catheters. This prevents trauma to mucous membranes ○
Use curved-tip catheters and head positioning (if not contraindicated). These facilitate secretion removal ○
.(from a specific side (right versus left lung
Instruct the patient to take several deep breaths before and after each nasotracheal suctioning procedure○
.and use supplemental oxygen as appropriate. This prevents suction-related hypoxia
Stop suctioning and provide supplemental oxygen (assisted breaths by Ambu bag as needed) if the patient○
.experiences bradycardia, an increase in ventricular ectopy, and/or desaturation
Use universal precautions: gloves, goggles, and mask as appropriate. If sputum is purulent, precautions ○
.should be instituted before receiving the culture and sensitivity report
Suctioning is indicated when patients are unable to remove secretions from the airways by coughing because of
.weakness, thick mucus plugs, or excessive mucus production

Institute appropriate isolation precautions for positive cultures (e.g., methicillin-resistant Staphylococcus •
.(aureus [MRSA] or tuberculosis

.Use humidity (humidified oxygen or humidifier at bedside). This loosens secretions •

Encourage oral intake of fluids within the limits of cardiac reserve. Increased fluid intake reduces the •
viscosity of mucus produced by the goblet cells in the airways. It is easier for the patient to mobilize thinner
.secretions with coughing

Administer medications (e.g., antibiotics, mucolytic agents, bronchodilators, expectorants) as ordered, noting •
.effectiveness and side effects

For patients with chronic problems with bronchoconstriction, instruct in use of metered-dose inhaler (MDI) •
.or nebulizer as prescribed

Consult respiratory therapist for chest physiotherapy and nebulizer treatments as indicated (hospital and •
home care/rehabilitation environments). Chest physiotherapy includes the techniques of postural drainage and
.chest percussion to mobilize secretions in smaller airways that cannot be removed by coughing or suctioning

Coordinate optimal time for postural drainage and percussion (i.e., at least 1 hour after eating). This prevents
.aspiration

For patients with reduced energy, pace activities. Maintain planned rest periods. Promote energy- •
.conservation techniques. Fatigue is a contributing factor to ineffective coughing
 For acute problem, assist with bronchoscopy. This obtains lavage samples for culture and sensitivity, and •
.removes mucus plugs

:If secretions cannot be cleared, anticipate the need for an artificial airway (intubation). After intubation •
.Institute suctioning of airway as determined by presence of adventitious sounds○
.Use sterile saline instillations during suctioning. This helps facilitate removal of tenacious sputum ○

.For patients with complete airway obstruction, institute cardiopulmonary resuscitation (CPR) maneuvers •
Education/Continuity of Care

Demonstrate and teach coughing, deep breathing, and splinting techniques. Patient will understand the •
.rationale and appropriate techniques to keep the airway clear of secretions

.Instruct patient on indications for, frequency, and side effects of medications •

.Instruct patient how to use prescribed inhalers, as appropriate •

.In home setting, instruct caregivers regarding cough enhancement techniques and need for humidification •

Instruct caregivers in suctioning techniques. Provide opportunity for return demonstration. Adapt technique •
.for home setting

For patients with debilitating disease being cared for at home (CVA, neuromuscular impairment, and others), •
instruct caregiver in chest physiotherapy as appropriate. This may also be useful for the patient with
bronchiectasis who is ambulatory but requires chest physiotherapy because of the volume of secretions and the
.inability to adequately clear them

.Teach patient about environmental factors that can precipitate respiratory problems •

Explain effects of smoking, including second-hand smoke. Smoking contributes to bronchospasm and •
.increased mucus production in the airways

Refer patient and/or significant others to smoking-cessation group, as appropriate, and discuss potential use •
.of smoking-cessation aids (e.g., Nicorette Gum, Nicoderm, or Habitrol) to wean off the effects of nicotine

.Instruct patient on warning signs of pending or recurring pulmonary problems •

.Refer to pulmonary clinical nurse specialist, home health nurse, or respiratory therapist as indicated •
•
(Nursing Care Plan of patient with Respiratory Acidosis (Primary Carbonic Acid Excess•
 RESPIRATORY ACID-BASE IMBALANCES•

The body has the remarkable ability to maintain plasma pH within a narrow range of 7.35–7.45. It does so
by means of chemical buffering mechanisms involving the lungs and kidneys. Although simple acid-base
imbalances (e.g., respiratory acidosis) do occur, mixed acid-base imbalances are more common (e.g., the
.(respiratory acidosis/metabolic acidosis that occurs with cardiac arrest

(RESPIRATORY acidosis (Primary carbonic acid EXCESS

Respiratory acidosis (elevated PaCO2 level) is caused by hypoventilation with resultant excess carbonic
acid (H2CO3). acidosis can be due to/associated with primary defects in lung function or changes in normal
.respiratory pattern. The disorder may be acute or chronic

Compensatory mechanisms include (1) an increased respiratory rate; (2) hemoglobin (Hb) buffering,
forming bicarbonate ions and deoxygenated Hb; and (3) increased renal ammonia acid excretions with
.reabsorption of bicarbonate

Acute respiratory acidosis: Associated with acute pulmonary edema, aspiration of foreign body, overdose of
sedatives/barbiturate poisoning, smoke inhalation, acute laryngospasm, hemothorax/pneumothorax,
atelectasis, adult respiratory distress syndrome (ARDS), anesthesia/surgery, mechanical ventilators,
excessive CO2 intake (e.g., use of rebreathing mask, cerebral vascular accident [CVA] therapy), Pickwickian
.syndrome

Chronic respiratory acidosis: Associated with emphysema, asthma, bronchiectasis; neuromuscular disorders
.(such as Guillain-Barré syndrome and myasthenia gravis); botulism; spinal cord injuries

CARE SETTING

This condition does not occur in isolation, but rather is a complication of a broader health problem/disease
or condition for which the severely compromised patient requires admission to a medical-surgical or
.subacute unit

RELATED CONCERNS

:.Plans of care specific to predisposing factors/disease or medical condition, e.g

Cerebrovascular accident (CVA)/stroke

Chronic obstructive pulmonary disease (COPD) and asthma

(Craniocerebral trauma (acute rehabilitative phase

Eating disorders: obesity

Alcohol: acute withdrawal

(Spinal cord injury (acute rehabilitative phase

Surgical intervention

(Ventilatory assistance (mechanical

OTHER CONCERNS

Fluid and electrolyte imbalances

Metabolic acidosis

Metabolic alkalosis
 Patient Assessment Database

.Dependent on underlying cause. Findings vary widely

ACTIVITY/REST

May report: Fatigue, mild to profound

May exhibit: Generalized weakness, ataxia/staggering, loss of coordination (chronic), to stupor

CIRCULATION

May exhibit: Low BP/hypotension with bounding pulses, pinkish color, warm skin (reflects vasodilation of
(severe acidosis

(Tachycardia, irregular pulse (other/various dysrhythmias

(Diaphoresis, pallor, and cyanosis (late stage

FOOD/FLUID

May report: Nausea/vomiting

NEUROSENSORY

(May report: Feeling of fullness in head (acute—associated with vasodilation

Headache, dizziness, visual disturbances

(May exhibit: Confusion, apprehension, agitation, restlessness, somnolence; coma (acute

(Tremors, decreased reflexes (severe

RESPIRATION

May report: Shortness of breath; dyspnea with exertion

May exhibit: respiratory rate dependent on underlying cause, i.e., decreased in respiratory center
depression/ muscle paralysis; otherwise rate is rapid/shallow

Increased respiratory effort with nasal flaring/yawning, use of neck and upper body muscles

Decreased respiratory rate/hypoventilation (associated with decreased function of respiratory center as in

(head trauma, oversedation, general anesthesia, metabolic alkalosis

Adventitious breath sounds (crackles, wheezes); stridor, crowing

TEACHING/LEARNING

.Refer to specific plans of care reflecting individual predisposing/contributing factors

Discharge plan

DRG projected mean length of inpatient stay: 4.9 days

May require assistance with changes in therapies for underlying disease process/condition

.Refer to section at end of plan for postdischarge considerations

 DIAGNOSTIC STUDIES

.ABGs: PaO2: Normal or may be low. Oxygen saturation (SaO2) decreased

.(PaCO2: Increased, greater than 45 mm Hg (Primary acidosis

.(Bicarbonate (HCO3): Normal or increased, greater than 26 mEq/L (compensated/chronic stage

.Arterial pH: Decreased, less than 7.35

.Electrolytes: Serum potassium: Typically increased

.Serum chloride: Decreased

.Serum calcium: Increased

.Lactic acid: May be elevated

.Urinalysis: Urine pH decreased

.Other screening tests: As indicated by underlying illness/condition to determine underlying cause

NURSING PRIORITIES

.Achieve homeostasis .1
.Prevent/minimize complications .2
.Provide information about condition/prognosis and treatment needs as appropriate .3

DISCHARGE GOALS

.Physiological balance restored .1

.Free of complications .2
.Condition, prognosis, and treatment needs understood .3
.plan in place to meet needs after discharge .4
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(norepinephrine (noradrenaline•

•
•
(epinephrine (adrenaline•
Catecholamines are "fight-or-flight" hormones released by the adrenal glands in response to stress.[1] They are•
.part of the sympathetic nervous system
They are called catecholamines because they contain a catechol or 3,4-dihydroxyphenyl group. They are derived•
[
from the amino acid tyrosine.[2
In the human body, the most abundant catecholamines are epinephrine (adrenaline), norepinephrine•
(noradrenaline) and dopamine, all of which are produced from phenylalanine and tyrosine. Various stimulant
.drugs are catecholamine analogs
.Catecholamines are water-soluble and are 50% bound to plasma proteins, so they circulate in the bloodstream•
Tyrosine is created from phenylalanine by hydroxylation by the enzyme phenylalanine hydroxylase. (Tyrosine is•
also ingested directly from dietary protein). It is then sent to catecholamine-secreting neurons. Here, several
reactions serially convert tyrosine to L-DOPA, to dopamine, to norepinephrine, and eventually to epinep
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