Sherpath Ch 41 Oxygenation

Question 1

Impaired Gas Exchange

Answer 1

is caused by the destruction of alveolar walls and is associated with an oxygen (O2) saturation (SpO2) of less than 90% and dyspnea.

Patient cues that would support this nursing hypothesis:

Patient diagnosed with emphysema
SpO2 90% or less
Adventitious breath sounds bilaterally
Respiratory rate 26 breaths per minute and shallow
Speaks in short sentences

Question 2

Activity Intolerance

Answer 2

Patient diagnosed with chronic bronchitis
SpO2 92% at rest and 84% after walking 20 feet
Respiratory rate 36 breaths per minute after exercise
Cannot walk more than 20 feet without sitting down to rest

Question 2

Impaired Airway Clearance

Answer 2

can be caused by bronchoconstriction and increased production of mucus. It is associated with thick sputum, prolonged coughing incidents, adventitious breath sounds, and dyspnea.

Patient cues that would support this nursing hypothesis:

Patient diagnosed with pneumonia
Decreased bilateral breath sounds in lower lungs
Cough with thick, green sputum

Question 3

Ineffective Tissue Perfusion

Answer 3

can be caused by decreased O2 levels in the blood and associated with fatigue with exercise and cyanosis.

Patient assessment data that would support this nursing hypothesis:

Patient sitting in wheelchair with O2 in place
Report of fatigue with ambulation
SpO2 92% with O2, 82% without O2

Question 3

Acute chest pain

Answer 3

is related to damage to the heart muscle, as evidenced by pain rating of 7 out of 10, increased respiratory rate, and diaphoresis.

Patient cues that would support this nursing hypothesis:

Patient diagnosed with acute myocardial infarction
Diaphoretic and respiratory rate 36 breaths per minute
Complains of nausea and difficulty breathing