DIANA KYLA A.

PUNAY
BSN-DASH-6

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

SUBJECTIVE Impaired Gas Impaired Gas SHORT TERM: Monitor for Restlessness is Short Term:
DATA: Exchange r/t Exchange is changes in an early sign of The patient has
“ Patient diaphoretic as defined as After 3 days, orientation and hypoxia. If a verbalized
verbalized evidenced by excess or deficit Patient behavior of hypoxia understanding of
headache, light headache, light in oxygenation verbalizes patients. increases due to the inventions
headed when headed when and/or carbon understanding of lack of blood given to improve
moving, irritable” moving,muscles dioxide oxygen and supply to the the patient's
are restless, elimination at other brain, mentation condition.The
irritable, lungs the alveolar therapeutic might get worse. vital signs were
OBJECTIVE are clear but capillary interventions. returned to its
DATA: diminished. membrane. normal range
After 3 days, Assess for signs Tachycardia, and manifested
“ Lungs are clear Patient of hypoxemia. restlessness, no signs of
but diminished” maintains clear diaphoresis, respiratory
“ Muscles are lung fields and headache, distress.
restless remains absent lethargy are all
of symptoms of signs of
BP: 140/80 respiratory hypoxemia.
mmHg distress. Long Term:
PR: 102 bpm The patient
RR: 24 cpm After 8 hours, Monitor Vital In hypoxia and manifested no
TEMP: 37.7 Patient maintain Signs. hypercapnia, signs of
Pulse Oximeter: optimal gas blood pressure , respiratory
94% exchange, heart rate, and distress.
unlabored respiratory rate
respirations at all increase. As
12-20 per the condition
minute, oximetry becomes more
results within severe BP may
normal range, drop, heart rate
blood gases continues to be
within normal rapid with
range, and arrhythmias and
baseline HR for respiratory
patients failure may be
present.
LONG TERM:

Patient will Monitor oxygen Pulse oximetry

maintain optimal saturation is a useful tool to
gas exchange continuously, detect changes
using pulse in oxygenation.
oximeters. An oxygen
saturation of
<90% (normal:
95% to 100%) or
a partial
pressure of
oxygen of <80
(normal: 80 to
100) indicates
significant
oxygenation
problems.

Increasing
Monitor ABG’s PaCO2 and
decreasing
PaO2 are signs
of respiratory
failure

Upright position
Position patient or semi-Fowler’s
with head of bed position allows
elevated, in a increased
semi-Fowler’s thoracic
position (head of capacity, full
bed at 45 descent of
degrees when diaphragm, and
supine) as increased lung
tolerated. expansion
preventing the
abdominal
contents from
crowding.

Absence of lung
Auscultate lung sounds, JVD
sounds. Also and/or tracheal
assess for the deviation could
presence of signify a
jugular vein Pneumothorax
distention (JVD) or Hemothorax.
or tracheal
deviation.