ASSESSMENT NURSING DIAGNOSIS
Subjective Cues:
The patients husband
verbalized, “The epigastric
pain worsens with food,
shortness of breath, nausea
and vomiting, difficulty
swallowing, diaphoresis and
loss of appetite.”.
Objective Cues:
 Shortness of
breath
 RR: 25 cpm
 O2: 93%
PLANNING
Impaired Gas Exchange Related to Goal of Care: At the end of 8-hour
Altered Oxygen Supply as nursing interventions, the client will be
Evidenced by Shortness of Breath, able to demonstrate improved
Respiratory Rate of 25 Cycles Per oxygenation as evidenced by sufficient
Minute and Oxygen Saturation of breathing pattern, respiratory rate, and
93% oxygen saturation.
 Administer oxygen as
ordered to maintain oxygen saturation
above 90%.
R: Supplemental oxygen improves gas
exchange and oxygen saturation. The
patient may need a nasal cannula or
other devices such as a venturi mask or
References: opti-flow to maintain an oxygen
https://rnlessons.com/impaired-gas- saturation above 90%.
exchange/
https://nurseslabs.com/impaired-  Administer medications
gas-exchange/ as ordered.
R: Medications depend on the etiology
of the disease process. The treatment
plan is very dependent on the condition
that is being treated.
 Assist the patient in an
upright (30 to 45 degrees) position as
their condition allows.
R: A proper body alignment allows for
adequate lung expansion and movement
of respiratory muscles to support the
lungs.
 Teach about coughing and
deep breathing methods.
R: Exercises such as pursed-lip
breathing and using the tripod position
aid in clearing secretions and increasing
lung expansion, helping facilitate gas
exchange.
 Schedule nursing care to
provide rest and minimize fatigue.
R: The hypoxic patient has limited
reserves; inappropriate activity can
increase hypoxia.
IMPLEMENTATION EVALUATION
 Goal Met! Patient manifested
improved oxygenation as evidenced by an
adequate breathing pattern, respiratory rate
of 21 cpm, and oxygen saturation of 97%.
 Goal Met! Oxygen therapy was
 Started intermittent initiated during manifestations of shortness
oxygen therapy via nasal cannula at of breath, increased respiratory rate as well
2 L/minute. as dropped in oxygen saturation.
 Goal Met!
 Administered The medications were given to help with the
omeprazole, cimetidine, patients’ current condition which can
metoclopramide, sodium inadvertently prevent occurrences of pain
bicarbonate and nifedipine sensation that worsens the patient’s
accordingly and as ordered. difficulty of breathing.
 Goal Met! Patient was placed in a
 Elevated the head of bed semi-Fowler’s position to help ease the
of the patient into a semi-Fowler’s difficulty of breathing especially during
position. occurrences of pain.
 Goal Met! Patient was performing
pursed-lip breathing as shortness of breath
 Taught the patient about was identified.
the pursed-lip breathing technique
when there was absence of any
discomfort.
 Scheduled nursing care  Goal Met! Schedule of nursing
considering the patients well-being. care was oriented to the patient prior such as
time of administration of prescribed
medications so that patient had the idea of
the time when to expect nursing care and
when to take a rest.