Evidence-Based Nursing Interventions for Patient Problems

QUESTION

Case Scenario: You are a student nurse working on an acute medical ward. You are working with a registered nurse and are allocated 4 patients. One of those patients is Ms. Alina Santiago. Alina was admitted to the ward overnight after presenting to the emergency department (ED) with increasing shortness of breath and a productive cough. Alina is a 27-year-old female, with a past medical history of anemia and has recently completed a course of antibiotics for an upper respiratory tract infection. Alina has been refusing oral fluids, states she is not thirsty, and is feeling fatigued. Alina has an allergy to penicillin and takes Ferro-grad C 325mg/500mg daily. Following handover, you complete a set of vital signs on Alina. You then identify the following patient problems for Alina. Patient Problems: 1. Alteration in breathing pattern. 2. Risk of fluid volume deficit. 3. Ineffective cardiac output. 4. Impaired gas exchange. BP: 100/80 mmHg HR: 132 bpm regular RR: 23 bpm, short, shallow breaths. Temperature: 38.3°C diaphoretic SpO2: 93% Room Air (RA) Pain: 2/10 (Numerical Pain Score)

A) Identify two (2) evidence-based nursing interventions for each of the four (4) patient problems identified.

b) Provide a rationale for each of the identified nursing interventions, including an explanation of the underlining physiology and/or pathophysiology.

Patient Problem: Alteration in breathing pattern

Evidence-based Nursing Intervention

1.

2.

Rationale

1.

2.

Problem: Ineffective cardiac output

Evidence-based Nursing Intervention

1.

2.

Rationale

1.

2.

Problem: Impaired gas exchange

Evidence-based Nursing Intervention

1.

2.

Rationale

1.

2.

Problem: Risk of fluid volume deficit

Evidence-based Nursing Intervention

1.

2.

Rationale

1.

2.

(APA) 7th edition referencing style.

With Citations.

ANSWER

Evidence-Based Nursing Interventions for Patient Problems

Patient Problem: Alteration in Breathing Pattern

Evidence-Based Nursing Intervention 1

Administer supplemental oxygen to maintain oxygen saturation within the target range (usually 92-95% or higher). Monitor oxygen saturation regularly and adjust oxygen flow rate as needed.

Rationale

In cases of altered breathing patterns and decreased oxygen saturation, providing supplemental oxygen helps improve oxygenation, prevent hypoxia, and reduce the workload on the heart. The patient’s oxygen saturation is currently low (93% on room air), indicating inadequate oxygen supply to tissues, which can lead to organ dysfunction and impaired gas exchange.

Evidence-Based Nursing Intervention 2

Assist the patient in assuming a comfortable and supported position, such as semi-Fowler’s or high-Fowler’s, to promote optimal lung expansion and ease of breathing.

Rationale

Elevating the head of the bed reduces diaphragmatic pressure, enhances lung expansion, and minimizes the effort required for breathing. This position allows for better chest excursion and helps prevent atelectasis, thus improving ventilation and gas exchange.

Patient Problem: Ineffective Cardiac Output

Evidence-Based Nursing Intervention 1

Administer prescribed medications promptly, such as diuretics (e.g., furosemide), to reduce excess fluid volume and alleviate strain on the heart.

Rationale

Diuretics help eliminate excess fluid, reducing preload on the heart and promoting more effective cardiac output. Fluid overload can lead to increased cardiac workload, congestion, and decreased tissue perfusion, exacerbating heart failure.

Evidence-Based Nursing Intervention 2

Monitor and record vital signs, especially heart rate and blood pressure, at regular intervals to assess changes in cardiac function and perfusion.

Rationale

Frequent monitoring of vital signs allows for early detection of any worsening cardiac output and immediate intervention. Elevated heart rate and low blood pressure indicate reduced cardiac output, which can lead to inadequate tissue perfusion and compromised organ function.

Patient Problem: Impaired Gas Exchange

Evidence-Based Nursing Intervention 1

Encourage deep breathing exercises, coughing, and effective airway clearance techniques to enhance lung expansion, mobilize secretions, and improve oxygenation.

Rationale

Impaired gas exchange can result from inadequate alveolar ventilation and retention of secretions. Deep breathing exercises and coughing help maintain lung compliance, prevent atelectasis, and facilitate the removal of mucus, improving overall gas exchange.

Evidence-Based Nursing Intervention 2

Position the patient for optimal lung ventilation, such as turning and repositioning every 2 hours, and encourage ambulation as tolerated to prevent pooling of lung secretions.

Rationale

Positioning the patient regularly helps distribute ventilation more evenly throughout the lungs and prevents stagnation of mucus in dependent areas. Ambulation promotes increased chest expansion and airflow, reducing the risk of retained secretions and improving oxygenation.

Patient Problem: Risk of Fluid Volume Deficit

Evidence-Based Nursing Intervention 1

Offer small, frequent sips of water or oral rehydration solutions to encourage fluid intake, even if the patient claims not to be thirsty.

Rationale

Fluid volume deficit poses a risk to organ function and perfusion. Encouraging regular fluid intake helps prevent dehydration, maintains hemodynamic stability, and supports adequate blood volume for optimal cardiac output.

Evidence-Based Nursing Intervention 2

Monitor intake and output closely, recording all oral intake, intravenous fluids, and fluid losses, such as urine output, vomiting, or sweating.

Rationale

Accurate monitoring of fluid intake and output allows for the early detection of imbalances. Tracking fluid balance is crucial for assessing the patient’s hydration status and ensuring effective management of fluid volume deficits.

Incorporating evidence-based nursing interventions for each patient problem addresses the physiological and pathophysiological issues observed in Ms. Alina Santiago’s condition. These interventions aim to optimize breathing patterns, cardiac output, gas exchange, and fluid balance, ensuring comprehensive care and promoting her overall well-being.