Name of Student: Señeres, Sta.

Ana NURSING CARE PLAN Section and Group number: BSN-3B Group 4

Name of CI: June Faith Hachero, RN MN

ASSESSMENT CUES NURSING DIAGNOSIS (RATIONALE) Desired Outcome Nursing Intervention Justification Evaluation
Pathophysiologic/Schematic
Diagram

Subjective Impaired Gas Exchange Short term goal: INDEPENDENT Short term goal:
related to alveolar- -After 4 hours of nursing -After 4 hours of nursing
Patient had two episodes capillary membrane intervention, the client will intervention, the client will
of cyanosis and was noted changes, altered O2 demonstrate improved 1. Assess respiratory 1. Useful in evaluating demonstrate improved
to be nauseated hence was supply and thick rate, depth, and effort, the degree of ventilation and adequate
ventilation and adequate
hooked to O2 and opted to secretions as evidenced including use of respiratory distress oxygenation as evidenced by
oxygenation as evidenced
be transferred to another by retractions, accessory muscles, and chronicity of the absence of cyanosis.
institution. expiratory grunting, and by absence of cyanosis. nasal flaring, and disease process
cyanosis (see diagram below) - Goal met
abnormal breathing
patterns. 2. Abnormal breath
Objective Long term goal: sounds are indicative
Vital Signs: After 5 days of nursing of numerous problems Long term goal:
2. Auscultate breath
T- 36.4 Definition: References: intervention, the client will (e.g., hypoventilation
sounds, note areas of
PR- 126 bpm be able to demonstrate decreased/ such as might occur -At the end of the 3-day
RR- 34 cpm Excess or deficit in Hockenberry, M. J., Wilson, with atelectasis or nursing intervention, the client
improved ventilation and adventitious breath
O2 Sat- 93% oxygenation and/or D., & Wong, D. L. (2013). presence of secretions, was able to demonstrate
adequate oxygenation as sounds as well as
--Noted to have retractions carbon dioxide Wong's essentials of improper endotracheal improved ventilation and
evidenced by: fremitus.
and cyanosis elimination at the pediatric nursing. St. Louis, (ET) tube placement, adequate oxygenation as
alveolar-capillary Mo: Elsevier/Mosby. collapsed lung) and evidenced by:
- Oxygen saturation within 3. Observe color of skin,
Physical Exam membrane (may be an mucous membranes, must be evaluated for
normal range (95-100%)
(+) good cry entity of its own, but it and nailbeds, noting further intervention - Oxygen saturation increased
(+) beginning Jaundice also may be an end -No retractions noted presence of peripheral to 97-100%
(+) murmurs result of other pathology cyanosis (nailbeds) or
Soft abdomen with an interrelatedness 3. In central cyanosis
central cyanosis -No retractions noted
between airway both the skin and
(circumoral).
Lab Results: clearance and/or mucous membranes
- Goal met
- HGB- 17.8 breathing pattern are affected due to
4. Monitor oxygen
problems) seriously impaired
Hct-50.8 saturation pulmonary function
continuously using from unventilated or
WBC: 19.7 pulse oximetry. underventilated
alveoli. Peripheral
 5. Monitor vital signs and cyanosis (skin only)
cardiac rhythm usually indicates
vasoconstriction or
6. Position client in semi- obstruction to blood
Fowler’s position, with flow.
References: an upright posture of
45 degrees if possible.
4. An oxygen saturation
NANDA of less than 88%
Doenges, M. E., 7. Encourage clearance
of secretions via (normal: 95% to 100%)
Moorhouse, M. F., & indicates significant
Murr, A. C. (2006). coughing,
expectoration, chest oxygenation problems.
Nurse's pocket guide:
Diagnoses, prioritized physiotherapy, and
interventions, and suctioning 5. All vital signs are
rationales. Philadelphia, impacted by changes
PA: F.A. Davis. in oxygenation.
DEPENDENT:

1. Provide 6. Elevation or upright

supplemental position facilitates
oxygen at lowest respiratory function by
concentration gravity; however,
indicated by client in severe
laboratory results distress will seek
and client position of comfort.
symptoms or
situation.
7. Mobilization of
2. Administer secretions may
medications as improve gas exchange.
indicated (e.g.,
inhaled and
systemic 1. To improve
glucocorticosteroid oxygenation and
s, antibiotics, evaluate between
bronchodilators, ideal and excessive
methylxanthines, oxygen therapy
antitussives/mucol 2. To improve gas
ytics, vasodilators). exchange, prevent and
 control symptoms,
reduce frequency and
3. Keep environment severity of
allergen and exacerbations
pollutant free 3. To reduce irritant
effect of dust and
chemicals on airways
Collaborative
1. Provide frequent
1. To decrease
contact and
anxiety, which
support to the
increases the
newborn and
child’s oxygen
family
demands

(Nurse’s Pocket Guide-

Diagnoses, Prioritized
Interventions, and
Rationales by Marilynn E.
Doenges, Mary Frances
Moorhouse, Alice C. Murr
pp.421-426)
Pathophysiology/Schematic Diagram