Assessment Diagnosis Planning Intervention Rationale Evaluation

Ineffective tissue Short term Independent Short term

Objectives: perfusion related to . Goal met
hypoxic injury as After 2 hours of Elevate head To promote
 ABGs evidence by: pH nursing on bed to 30 circulation After 2 hours of
pH -7.23 -7.23 intervention the degrees nursing
(PaCO2) 62 mm patient will intervention the
(PaCO2) 62 mm Hg(8.250kPa)l maintain adequate Avoid neck patient will able
Hg (8.250kPa)level (Pao2) 50 mm Hg circulating blood flexion and To avoid to maintained
(6.65 kPa) volume as extreme obstruction of adequate
(Pao2) 50 mm Hg SPO2 level 76% evidence by : RR- hip/knee arterial and circulating blood
(6.65 kPa) (0.76) 26 breaths/min extension venous blood volume as
RR- 30breaths/min SPO2 level- flow evidenced by :
SPO2 level 82% Serum Lactate 92%(0.92) Review laboratory RR-26
(0.82) 36.04mg/dl data (ABGs, BUN, breaths/min
Long term creatinine, SPO2 level-
 RR-30breaths/min electrolytes, Upright 92%(0.92)
After 4 hours of international positioning
 Serum Lactate nursing normalized ratio, promotes Long term
36.04mg/dl intervention the and prothrombin improved Partially
patient will regain time alveolar gas Goal met
and maintain or partial exchange.
blood gas thromboplastin After 4 hours of
parameters. time) if nursing
anticoagulants are intervention the
utilized for patient will able
treatment. Diuretics aids in to regained and
Review laboratory the excretion of maintained blood
data (ABGs, BUN, excess body gas parameters.
creatinine, fluids.
electrolytes,
international
normalized ratio,
and prothrombin Obtaining the
time blood pH and
or partial the levels of
thromboplastin dissolved
time) if Oxygen and
anticoagulants are Carbon
utilized for Dioxide in the
treatment. blood
Review laboratory
data (ABGs, BUN,
creatinine,
electrolytes,
international
normalized ratio,
and prothrombin
time
or partial
thromboplastin
time) if
anticoagulants are
utilized for
treatment.

Position patient
properly in a
semi-Fowler’s
to high-Fowler’s
as tolerate

Dependent

Give Furosemide
as ordered

Collaborative:
Refer to other
medical
technologist for
further blood and
abg analysis