Nursing Intervention for Ineffective Airway Clearance, Impaired Gas Exchange and Dehydration Leading to Fluid Volume Deficit (FVD)

Running Head: NURSING INTERVENTION
Nursing Intervention
Name of the Student:
Name of the University:
Author’s note:

NURSING INTERVENTION1
1. Five health issues identified:
The given case study is about Jim Cooper, a 69 year old adult. The five health issues
identified in Jim includes:
1. Impaired gas exchange
2. Ineffective airway clearance
3. Dehydration leading to fluid volume deficit (FVD)
4. Alcohol withdrawal
5. He has a risk of depression due to loneliness.
The identified health concerns of Jim are mentioned of which three highest priority health
issues include
1. Ineffective airway clearance
2. Impaired gas exchange
3. Dehydration leading to fluid volume deficit (FVD)
2. Three highest priority health issue:
Ineffective airway clearance can be defined as the health condition involving
complications in maintaining a clear airway. It is the inability of the system to clear
secretions or obstructions from the respiratory tract (Pascoal et al., 2016). The maintenance of
a clear airway is indeed a critical factor to life. It is characterized by abnormal breath sounds,
abnormal respiratory rate, rhythm and depth, dyspnea, excessive secretions, hypoxemia,
inability to remove airway secretions, absent cough and orthopnoea (Hooper et al., 2015) (de
Sousa, Lopes and da Silva, 2015). Sputum contains lower respiratory tract secretions,
oropharyngeal as well as the nasopharyngeal materials, microorganisms and the cells as well.
Mucous hypersecretion and impaired airway clearance as well as abnormal amount of airway

NURSING INTERVENTION2
secretion negatively impacts the pulmonary function reduces the defence system of the lung.
All these physiological changes elevate the risk of lung infection and progress to neoplasia.
Extensive damage of the cilia followed by hypersecretion of mucus poses a threat if the
airflow dependant mucus clearance is impaired and it is important for maintenance of the
airway hygiene as well.
Impaired gas exchange is defined as excess or deficit in the oxygen or carbon dioxide
elimination at the alveolar-capillary membrane. At the alveolar capillary membrane surface
the diffusion of the prime respiratory gases, carbon dioxide and oxygen occur exploiting the
concentration differences between them. The difference in the concentration is maintained by
the ventilation occurring in the alveoli and perfusion of the pulmonary capillaries. This
balance when disrupted causes impaired gas exchange. This can also cause the alveoli to
collapse. It causes collapse of the alveoli and impaired ventilation (Castellan et al., 2016). It
impacts the oxygenation of the tissues which is indeed a vital function for living. This is a
symptom associated with respiratory disorders linked with impaired airways (Hooper et al.,
2014). It is also related to acute respiratory infection that negatively impacts the functionality
of the respiratory system and contributes to the signs and symptoms of the onset of the same.
If left untreated it can lead to pulmonary edema, pneumonia, atelectasis and acute respiratory
distress syndrome (Pascoal et al., 2016).
Dehydration leading to fluid volume deficit (FVD) is the third health priority issue
identified. Fluid volume deficit is also termed as hypovolemia that is excessive loss of the
extracellular fluid from the body (Marra et al., 2016). This syndrome is observed as a result
of the depletion of the total sodium content in the body. This extracellular fluid constitutes
almost 20% of the body weight of the individual and exploits the blood plasma, spinal cord
fluid, fluid in between cells and lymph. It is a health compromised condition where the rate of
fluid output exceeds the rate of fluid intake (Begg, 2017). The consequences of the fluid