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NURS2466

NursingDiagnosis: Impaired gas exchange related to ventilation-perfusion


imbalance secondary to pneumonia definingcharacteristics(asevidenced by):
dyspnea, restlessness, lungs with bibasilar crackles, O2 sat 86%

Outcome: The client will have adequate gas exchange, O2sat 90%or above, no
cyanosis, and remain oriented

Interventions and Rationales


(italicized) Evaluation

1. Assess respirations: note quality, rate 1. 0800- SOB with exertion, respirations 24,
rhythm, depth, dyspnea on exertion, use sitting on edge of bed. 1200- respirations
of accessory muscles, position. 16, less dyspniec.
Abnormality indicates respiratory
2. Monitor for changes in vital signs. Hypoxia 2. 0800- BP 108/60 pulse 98;
causes BP, heart rate and respiratory rate 1200- BP 114/70 pulse 86
to rise and then drop as it becomes more
severe.

3. Encourage client to cough and deep 3. Occasional productive cough with thick
breathe. Rids airway of secretions. green sputum

4. Auscultate breath sounds for advenitious 4. 0800- lungs with coarse crackles
sounds. May indicate poor gas exhange. throughout ; 1200- lungs with crackles in
bases

5. Note changes in O2 sat. Indicates the 5. 0800- O2 sat 86%; 1200- O2 sat 90%
effectiveness o f gas exhange.

6. Maintain oxygen therapy. Shows the 6. 0800 oxygen at 3 liters; 1200- oxygen at 2
effectiveness of oxygenation. ½liters

7. Adminster respiratory treatments ordered. 7. 1100-Nebulizer treatment given- coughed


To prevent or reverse atelectasis. up thick green sputum. Lungs with fine
crackles in bases following tx.