Priority Nursing Diagnosis Impaired gas exchange related to inability to swallow effectively as evidenced by failed swallow evaluation, crackles

on auscultation, diminished lung sound in bases, and aspiration pneumonia

Goal Improved gas exchange
Outcome Criteria

Interventions

Scientific Rationale
Frequent monitoring of pt. O2
saturation will help keep the pt. In
the desired range for optimal gas
exchange. Turn, cough, deep
breathing exercises will help pt.
To expand lungs on a regular basis
and clear secretions. Monitor CXR
to assess pt. Progress, and be able
to document status and adjust
plan of care accordingly.

Evaluation
Met- Pt. Oxygen saturation was between 96
and 99 percent on room air after several days
in hospital.

1. Patient's oxygen saturation will be

above 92% by discharge

1a. Monitor O2 sat. Q4 hours

1b. Encourage TCDB Q2 hours
1c. Monitor CXR reports when available

2. Patient will not aspirate during

hospital stay

2a. Place order for swallow evaluation

per MD order upon admission
2b. Monitor swallowing with every meal
2c. Keep HOB elevated above 30 degrees
at all times

It is important to have a swallow

evaluation done on admission for
any pt. having difficulty
swallowing. A proper diet can
then be ordered. Continue to
monitor at each meal, and make
sure they are positioned
appropriately.

Partially met- Patient was placed on a nectar

thick liquid, and pureed solid diet. He is
tolerating well with no signs of further
aspiration.

3. Patient will have clear lung sounds by

discharge

3a. assess lung sounds Qshift

3b. Encourage pt to be OOB TID
3c. Administer bronchodialators TID and
PRN

It is important to assess pt every

shift to know when something
changes, and also to be able to
compare with previous shift and
note improvement. Being oob

Partially met- upon assessment of lungs, I

auscultated clear sounds throughout with
diminished sounds in bases.

frequently is necessary for proper

lung expansion. Pt can take
deeper breaths and will be safer
for meal time aspiration
precautions. Bronchodialators
relax the smooth muscle of the
bronchial tree allowing for any
secretions to loosen and be
moved out with greater ease.