Ackley: Nursing Diagnosis Handbook, 9th Edition
Case Study – Morrie Flack (Impaired Gas Exchange)
Case Studies Answers
Case Scenario
“I can’t breathe!” Morrie gasped for breath. “Help me!” Morrie looks up at you, his nurse, with
eyes filled with fear. He raises the head of the bed farther with the control and continues to gasp
for breath. You feel your own anxiety increasing, like Morrie’s anxiety is contagious. You push
the overbed table so Morrie can lean forward on it, sit on his bed, and work with him to do
pursed lip breathing and slow his breathing. You give him all the medications that he can have,
and you pray he gets better.
Nursing Assessment
Morrie, aged 45, has chronic obstructive pulmonary disease (COPD). He has been suffering for 5
years and is frequently a client on the respiratory nursing unit. He stopped smoking once
diagnosed, but he still has significant lung disease. His vital signs are: 180/92-100.2-116, 28. His
lung sounds are wheezing with loud crackles throughout. Oxygen saturation is 84 mm Hg. He
has oxygen per Venturi mask. His toes and fingers are cyanotic, as are his oral mucous
membranes.
A. ASSESS
1. Identify significant symptoms by underlining them in the assessment. See above.
2. List those symptoms that indicate the patient has a health problem (those you have
underlined).
“I can’t breathe!”
gasped for breath
“Help me!”
eyes filled with fear
anxiety is contagious
chronic obstructive pulmonary disease
frequently a client on the respiratory nursing unit
stopped smoking once diagnosed
significant lung disease
180/92-100.2-116, 28
lung sounds are wheezing, with loud crackles throughout
oxygen saturation is 84
oxygen per Venturi mask
toes and fingers are cyanotic, as are his oral mucous membranes
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Case Studies Answers
3. Group the symptoms that are similar
“I can’t breathe!”
gasped for breath
“Help me!”
chronic obstructive pulmonary disease
frequently a client on the respiratory nursing unit
stopped smoking once diagnosed
significant lung disease
180/92-100.2-116, 28
lung sounds are wheezing, with loud crackles throughout
oxygen saturation is 84
oxygen per Venturi mask
eyes filled with fear
anxiety is contagious
B. DIAGNOSE
1. Select possible nursing diagnoses for Morrie.
Do this by looking at the list of nursing diagnoses in the handout or in your book, Nursing
Diagnosis Handbook: A Guide to Planning Care, Appendix A. Look up the diagnosis of
abdominal surgery in Section II of your book or this handout in the reference section. Also look
up symptoms of hypertension, diabetes, and overweight in Section II of the book or in the
reference section of this handout.
Possible nursing diagnoses:
___Impaired Gas Exchange_____________________________________
___ Fear____________________________________________________
2. Validate the possible nursing diagnoses.
Compare the signs and symptoms (defining characteristics) that you have identified from your
patient assessment with the defining characteristics for the nursing diagnosis that you have
selected. Also read the definition and determine if this diagnosis fits this patient.
Validated nursing diagnoses for Morrie Flack include:
_____Impaired Gas Exchange_____________________________________
___ Fear____________________________________________________
3. Write a nursing diagnostic statement for one of the nursing diagnoses by combining the
nursing diagnosis label with the related to (r/t) factors.
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a. The label is the title of the nursing diagnosis as defined by NANDA.
b. A related to (r/t) statement describes factors that may be contributing to or causing the
problem that resulted in the nursing diagnosis.
NANDA label:____Impaired Gas Exchange________________________________
Related to factors (r/t): ____alveolar-capillary membrane changes__________________
The complete nursing diagnostic statement is:
__Impaired Gas Exchange (r/t): alveolar-capillary membrane changes_________________
C. PLAN
1. Write an outcome to help Morrie Flack resolve the symptoms (defining characteristics).
Refer to Section III of the handouts for the above diagnosis.
NOC outcome: ____Respiratory Status: Gas Exchange__________________________
Fill out the grid with NOC indicators and the appropriate Likert scale.
Select the appropriate point on the Likert scale to measure the client’s current status.
INDICATOR Severe
Substantial
Moderate
Mild
No Deviation
Deviation
Deviation from
Deviation from
Deviation from
from Normal
from Normal
Normal Range
Normal Range
Normal Range
Range 5
Range 1
2
3
4
Arterial pH
1*
2
3
4
5
PaO2
1
2*
3
4
5
PaCO2
1
2*
3
4
5
Oxygen
1*
2
3
4
5
1
2
3*
4*
5
Saturation
Cognitive
Status
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Case Studies Answers
2. Or write a client outcome to help Morrie resolve the symptoms (defining characteristics).
Refer to Section III of the Ackley/Ladwig text.
Outcome: ____Demonstrate improved ventilation and adequate oxygenation as evidenced by
blood gas levels within normal parameters for that client______________
3. Select appropriate NIC interventions from the Ackley/Ladwig text.
NIC intervention: ___Acid-Base Management________________________________
4. Select appropriate NIC activities.
a. ___Monitor for symptoms of respiratory failure____________________
b. ___Monitor determinants of tissue oxygen delivery_________________
Note: The Ackley/Ladwig text gives two sample NIC activities.
Outcome: _________________________________________________________
5. Select interventions from the Section III care plan on the previously mentioned nursing
diagnosis that you think will be appropriate for Morrie Flack and that will enable the nurse to
accomplish the outcome.
Nursing interventions and rationales


•
•
•
Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory
muscles, and nasal flaring. Normal respiratory rate is 14 to 16 breaths/min in the adult
(Bickley & Szilagyi, 2009). EBN: When the respiratory rate exceeds 30 breaths/min,
along with other physiological measures, a study demonstrated that a significant
cardiovascular or respiratory alteration existed (Considine, 2005; Hagle, 2008).
Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may
alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia.
In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds
may be diminished or distant with air trapping (Bickley, Szilagyi, 2009).
Monitor the client’s behavior and mental status for the onset of restlessness, agitation,
confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental
status can be early signs of impaired gas exchange (Simmons & Simmons, 2004). In the
late stages the client becomes lethargic and somnolent.
Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results as
available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial
pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates
significant oxygenation problems (Clark et al, 2006).
Observe for cyanosis of the skin, especially note color of the tongue and oral mucous
membranes. Central cyanosis of the tongue and oral mucosa is indicative of serious
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Case Studies Answers
•
•
•
•
•
•
5
hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be due
to activation of the central nervous system or exposure to cold and may or may not be
serious (Bickley & Szilagyi, 2009).
Position clients in semi-Fowler’s position, with an upright posture at 45 degrees if
possible. EB: Research done on clients on a ventilator demonstrated that being in a 45degree, upright position increased oxygenation and ventilation (Speelberg & Van Beers,
2003). Research on healthy subjects demonstrated that sitting upright resulted in higher
tidal volumes and minute ventilation versus sitting in a slumped posture (Landers et al,
2003).
If the client has unilateral lung disease, alternate semi-Fowler’s position in an upright
posture with a lateral position (with 10- to 15-degree elevation and ‘‘good lung down’’
for 60 to 90 minutes). This method is contraindicated for clients with pulmonary abscess
or hemorrhage or interstitial emphysema. Gravity and hydrostatic pressure cause the
dependent lung to become better ventilated and perfused, which increases oxygenation
(Marklew, 2006).
If the client has bilateral lung disease, position the client in either semi-Fowler’s or a
side-lying position, which increases oxygenation as indicated by pulse oximetry (or, if the
client has a pulmonary catheter, venous oxygen saturation).
Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after
turning. If it drops below 10% or fails to return to baseline promptly, turn the client back
into the supine position and evaluate oxygen status. If the client does not tolerate turning,
consider use of a kinetic bed that rotates the client from side to side in a turn of at least 40
degrees. EBN: Use of the kinetic bed was shown to decrease development of atelectasis
and ventilator associated pneumonia in critically ill clients (Ahrens, 2004).
If the client is acutely dyspneic, consider having the client lean forward over a bedside
table, resting elbows on the table if tolerated. Leaning forward can help decrease
dyspnea, possibly because gastric pressure allows better contraction of the diaphragm
(Langer et al, 2009). This is called the tripod position and is used during times of
distress, including when walking, leaning forward of the walker.
Help the client deep breathe and perform controlled coughing. Have the client inhale
deeply, hold the breath for several seconds, and cough two or three times with the mouth
open while tightening the upper abdominal muscles as tolerated. Controlled coughing
uses the diaphragmatic muscles, which makes the cough more forceful and effective.
NOTE: If the client has excessive fluid in the respiratory system, see the interventions for
Ineffective Airway clearance.
▲ Monitor the effects of sedation and analgesics on the client’s respiratory pattern; use
judiciously. Both analgesics and medications that cause sedation can depress respiration
at times. However, these medications can be very helpful for decreasing the sympathetic
nervous system discharge that accompanies hypoxia.
• Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has
limited reserves; inappropriate activity can increase hypoxia.
▲ Administer humidified oxygen through an appropriate device (e.g., nasal cannula or
Venturi mask per the physician’s order); aim for an oxygen (O2) saturation level of 90%
or above. Watch for onset of hypoventilation as evidenced by increased somnolence.
There is a fine line between ideal or excessive oxygen therapy; increasing somnolence is
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Case Studies Answers
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caused by retention of carbon dioxide (CO2) leading to CO2 narcosis (Simmons &
Simmons, 2004; Wong & Elliott, 2009).
• Assess nutritional status including serum albumin level and body mass index (BMI).
Weight loss in a client with COPD has a negative effect on the course of the disease; it
can result in loss of muscle mass in the respiratory muscles, including the diaphragm,
which can lead to respiratory failure (Celli & MacNee, 2004; Odencrants et al, 2008.).
• Assist the client to eat small meals frequently and use dietary supplements as necessary.
For some clients, drinking 30 mL of a supplement such as Ensure or Pulmocare every
hour while awake can be helpful.
▲ Watch for signs of psychological distress including anxiety, agitation, and insomnia.
Refer for counseling as needed. EBN: One study demonstrated a clear association
between hospitalization for COPD and psychological distress (Andenaes et al, 2004).
▲ Refer the COPD client to a pulmonary rehabilitation program. EB: A Cochrane review
demonstrated that pulmonary rehabilitation has been shown to relieve dyspnea and
fatigue, help the patients deal with emotions, and enhance the clients’ sense of control
over the disease (Lacasse et al, 2006). Pulmonary rehabilitation is now considered a
standard of care for the client with COPD (Nici, 2009).
D. IMPLEMENT
The next step in the nursing process is to give the nursing care using the nursing interventions.
E. EVALUATE
Evaluation of NOC Outcome
INDICATOR
Arterial pH
Rating at
admission
1
Rating at
discharge
4
Rating 6
months later
4
PaO2
1
3
4
PaCO2
1
3
4
Oxygen
Saturation
Cognitive
Status
Average of
indicators
1
3
4
3
5
5
1.4
3.6
4.2
Morrie had improved by discharge but still had significant disease. He was referred to a
pulmonary rehabilitation program, with both an educational and exercise component. The
program helped Morrie learn how to prevent exacerbations, handle shortness of breath, and
increase exercise capacity. Morrie was able to return to work on a part-time basis.
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