You are on page 1of 2

IMPAIRED GAS EXCHANGE

Date/Time August 19 2010 3PM Thursday Cues S: Maglisod ko ug ginhawa tapos malipong ko kadugayan. O: - with O2 1-2 lpm via Nasal Cannula - RR=22cpm - Hemoglobin =42 (140-180 g/L) -with 1 unit PRBC available. Need A C T I V I T Y E X E R C I S E P A T T E R N Diagnosis Impaired Gas Exchange r/t decreased O2carrying capacity of blood secondary to anemia. Hemoglobin is a component of blood which is responsible in carrying Oxygen throughout the body. Patients who are anemic has low level of hemoglobin, with this he/she will manifest shortness of breathing due to lack of oxygen supply and exchange. Objectives Within 8 hours span of care, patient will be able to manifest signs of good gas exchange as evidenced by: 1. Maintain RR within normal range (16-24cpm) Nursing Intervention 1. Monitor VS especially RR. For baseline data and to evaluate respirations. 2. Elevate head of bed/position client appropriately. Elevation/upright position facilitates respiratory function by gravity this is also to facilitate effective breathing. Evaluation August 19 2010

GOAL MET That within 8 hours span of care, our patient was able to manifest signs of good gas exchange as evidenced by: 1. RR=21cpm 2. Dyspnea and other unusualities not noted. 3. He participated attentively and cooperatively with the health teachings that

2. Absence of dyspnea and other unusualities. 3. Encourage frequent position changes, deep3. Participate in breathing/directed treatment regimen coughing exercises, (e.g., breathing Promotes optimal chest exercises and use expansion, mobilization of of oxygen) within secretions, and oxygen level of diffusion. ability/situation. 4. Provide supplemental oxygen (via cannula) For oxygenation and provide proper ventilation.

88

5. Encourage adequate rest and limit activities to within client tolerance. Promote calm/restful environment. Helps limit oxygen needs/consumption. 6. Transfuse with blood as ordered. To supplement Hemoglobin in the body. 7. Encourage to eat foods rich in Vitamin C, Protein and Iron. To supplement patients body, Vitamin C and Protein to boost the immune system, and Iron for the production of RBC.

I have rendered. Salamat sir ha, karon kabalo nako unsa ako buhaton if maglisod ko ug ginhawa, sama sa pagsaka sa taas na part sa bed ug magpahuway ug i-limita ang akong gipangbuhat.

89