NUR 2466 S NursingD nosis: Im iag paired g exchang related to ventilation-perfusion as e im balance secondary to pneum onia definingcharacteristics

(asevidenced by): dyspnea, restles snes lung with bibasilar crackles, O2 sat 86% s, s Outcom The client will have adequate g exchang O2sat 90%or above, no e: as e, cyanos and rem oriented is, ain Interventions and R ationales (italicized)
1. Assess respirations: note quality, rate rhythm, depth, dyspnea on exertion, use of accessory muscles, position. Abnormality indicates respiratory 2. Monitor for changes in vital signs. Hypoxia causes BP, heart rate and respiratory rate to rise and then drop as it becomes more severe. 3. Encourage client to cough and deep breathe. Rids airway of secretions. 4. Auscultate breath sounds for advenitious sounds. May indicate poor gas exhange.

1. 0800- SOB with exertion, respirations 24, sitting on edge of bed. 1200- respirations 16, less dyspniec. 2. 0800- BP 108/60 pulse 98; 1200- BP 114/70 pulse 86

3. Occasional productive cough with thick green sputum 4. 0800- lungs with coarse crackles throughout ; 1200- lungs with crackles in bases 5. 0800- O2 sat 86% 1200- O2 sat 90% ;

5. Note changes in O2 sat. Indicates the effectiveness o f gas exhange. 6. Maintain oxygen therapy. Shows the effectiveness of oxygenation. 7. Adminster respiratory treatments ordered. To prevent or reverse atelectasis.

6. 0800 oxygen at 3 liters; 1200- oxygen at 2 ½liters 7. 1100-Nebulizer treatment given- coughed up thick green sputum. Lungs with fine crackles in bases following tx.