Assessment Diagnosis Planning Intervention Rationale Evaluation

Objectives: Impaired Gas Short term: Independent: Independent: Short term:

RR: 41 breaths Exchange RT After 8 hours -Assist with -To maintain After 8 hours
per minute, increase of nursing intubation as ventilator of nursing
O2 sat: 94% at 4 capillary intervention directed. settings, as intervention
L/min via nasal membrane patient will ordered, and patient was
cannula. permeability able to monitor the able to
(+) diaphoretic as evidenced gradually patient's gradually
(+) rapid shallow by o2 sat of improve of response. improve of
breathing. 94% and oxygen - Raise the head - Semi-Fowler’s oxygen
(+) crackles were chest X-ray saturation of the bed position saturation
audible showed within promotes a within
throughout the low lung normal patient’s chest normal
bilateral lung volumes and range.  expansion. range. 
fields. bilateral - Monitor oxygen -To create
Patient was atelectasis Long term: saturation baseline data Long term:
intubated After a week continuously, and monitor After a week
Chest X-ray: of nursing using pulse prognosis of nursing
low lung volumes intervention oximeter. intervention
and bilateral patient will -Observe the - Discoloration patient was
atelectasis able to color of the skin of the skin or able to
maintain and mucous nail beds maintain
oxygen membrane Peripheral oxygen
saturation -Monitor cyanosis) may saturation
within evident further within
normal reduction of normal
range. oxygen levels. range.
- Perform - To remove
suctioning, as mucous
needed secretions

Dependent: Dependent:

-Administer -For the

medications as prognosis of the
ordered. disease
indicated.

Collaborative: Collaborative:

-Refer the chest -For further

physiotherapist. interventions
needed.

https://nursestudy.net/impaired-gas-exchange-nursing-care-plans/

https://opentextbc.ca/clinicalskills/chapter/5-5-management-of-hypoxemia/
https://thorax.bmj.com/content/63/Suppl_6/vi1