Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Date: 08/25/2021 Impaired gas Within 30 minutes Independent After my 30 minutes

Time: 8:15 AM exchange related to span of my nursing 1. Assess respirations: quality, 1. Rapid, shallow span of my nursing
altered delivery of care rate, pattern, depth, and breathing, and care:
Objective cues: oxygen as evidenced Client will be able to breathing effort. hypoventilation affect gas Client maintained a
Abdominal by tachypnea. maintain respiration exchange by affecting C02 respiration of 18.
breathing of 25 to 20cpm levels. Flaring of the
PaO2 of 73mmHg Rationale: . nostrils, dyspnea, use of
and an A-a O2 Impaired gas accessory muscles, -GOAL MET-
gradient of 32mmHg exchange occurs tachypnea and or apnea
112 bpm due to alveolar- are all signs of severe
RR-26 CPM capillary membrane distress that require SHEILA MAE SACLOT
changes, such as immediate intervention. SN,UM
fluid shifts and fluid
collection into 2. Auscultate lung sounds. 2. Absence of lung
interstitial space and Also assess for the presence sounds, JVD and/or
alveoli. This leads to of jugular vein distention tracheal deviation could
excess or deficit of (JVD) or tracheal deviation. signify a Pneumothorax or
oxygen at the Hemothorax.
alveolar capillary
membrane with 3. Assess for signs of 3. Tachycardia,
impaired carbon hypoxemia. restlessness, diaphoresis,
dioxide elimination. headache, lethargy and
confusion are all signs of
hypoxemia.

4. Monitor vital signs. 4. To obtain baseline data

5. Monitor ABG
6. Use Pulse Oximetry to
monitor O2 Saturation ;
assess arterial blood gases
(ABGs).
7. Monitor heart rate and
rhythm and blood pressure.
8. Position the patient with
head of bed 45 degrees (if
tolerated).
9. Pace activities and provide
rest periods to prevent
fatigue.
Dependent:
10. Administer oxygen
therapy as ordered
5. Increase PaCO2 and
decreasing PaO2 are signs
of respiratory failure.
6. Pulse oximetry is used
to detect changes in
oxygenation.
7. Tachycardia is usually
present as a result of
fever and/or dehydration
but may represent a
response to hypoxemia.
8. Promotes better lung
expansion and improved
gas exchange.
9. Even simple activities,
such as bathing, can
increase oxygen
consumption and cause
fatigue.
10. The purpose of
oxygen therapy is to
maintain adequate
oxygenation.