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Impaired Gas Exchange

Impaired Gas Exchange



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Published by iloveanne
nursing care plan for patient with impaired gas exchange
nursing care plan for patient with impaired gas exchange

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Published by: iloveanne on Aug 25, 2009
Copyright:Attribution Non-commercial


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AssessmentNursing DiagnosisScientificExplanationPlanningInterventionRationaleEvaluationSubjective:“Mabilis angkanyangpaghinga” asstated.Objective:-RR: 28 cpm-PR: 102 bpm-wheezes uponauscultation-with pulseoxymeter -with mechanicalventilator Impaired GasExchange relatedto altered oxygensupply(obstruction of airways bysecretion) asevidenced bywheezes uponauscultationEntry of noxiousparticles or gasesto the lungs
Release of mediators
Abnormalinflammation of thelungs
Scar tissueformation
Narrowing of airway lumen
Airflow limitations
Impaired gasexchange
wheezesReference:PathophysiologyDischargeOutcome:After 3 days of nursingintervention theclient:-Manifest absenceof wheezes uponauscultation-Attain normalbreathing patternof 20 cpmShort-termoutcome:After 2 hoursof nursingintervention theclient:-Demonstrateimprovedventilation andadequateoxygenation of tissues by ABG of:pH:7.35-7.45paCO2: 35-45mmHgIndependent:-Monitor skin andmucous membranecolor -Elevate head of thebed, assist patient toassume position toease work of breathing-Suction whenneeded-Auscultate breathsounds, noting areasof decreased air-flowor presence of adventitious sound-Palpate for fremitus-Duskiness andcentral cyanosisindicate advancedhypoxemia-Oxygen deliverymay be improvedby uprightsuctioning-Suctioning isrequired whencough is ineffectivefor expectorationof secretions-Presence of wheezes mayindicatebronchospasm/retained secretions-Decrease of vibratory tremorssuggest fluidcollection or air tappingDischargeOutcomeACHIEVED:After 3 days of nursingintervention theclient:-Manifestedabsence of wheezes uponauscultation- Attained normalbreathing patternof 20 cpmShort-termoutcomeACHIEVED:After 2 hoursof nursingintervention theclient:-Demonstratedimprovedventilation andadequateoxygenation of tissues by ABG of:pH:7.35-7.45

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