Assessment Diagnosis Planning Intervention Rationale Evaluation

● Personal hx: Impaired After 4 hours of Assess respirations: Rapid, shallow After 4 hours of
(+) smoking gas nursing quality, rate, pattern, breathing and nursing
● RR: 28 exchange intervention, depth and breathing hypoventilation intervention,
● HR: 112 related to patient will effort. affect gas exchange patient
● 8-8-21 altered maintain an by affecting CO2 maintained an
O2 Sat: 91% oxygen optimal gas levels. Flaring of the optimal gas
(+) dob supply exchange as nostrils, dyspnea, exchange as
● 8-12-21 evidenced by: use of accessory evidenced by:
ABG: PCO2 - 22 Definition: muscles, tachypnea
mmHg Excess or Awake and and/or apnea are all Awake and
PO2 - 194 deficit in responsive. signs of severe responsive.
mmHg oxygenatio distress that require
● (+) crackles n and/or O2Sat ranges immediate O2Sat of 99%
carbon within 95%-100% Monitor alteration in vital intervention.
dioxide signs. RR of 18 bpm.
elimination RR ranges within Initially with hypoxia
at the 12-20 bpm. and hypercapnia HR of 80 bpm.
alveolar- blood pressure,
capillary HR ranges within heart rate and Noted ABGs
membrane. 60-100 bpm. respiratory rate all within normal
increase. As the ranges.
Noted ABGs condition becomes
within normal more severe BP may Noiseless
ranges. drop, heart rate respirations upon
continues to be auscultation.
Clear lung fields rapid with
as evidenced by Assess for signs of arrhythmias and
noiseless hypoxemia. respiratory failure
respirations. may ensure.

Tachycardia,
restlessness,
diaphoresis,
Note ABG results as headache, lethargy
available and note and confusion are all
changes. signs of hypoxemia.

Increasing PaCO2
Position patient with head and decreasing
of bed 45 degrees (if PaO2 are signs of
tolerated). respiratory failure.

Promotes better
Encourage slow deep lung expansion and
breathing. improved gas
exchange.

Administer oxygen as Promotes deep

ordered. inspiration.

Supplemental
oxygen may be
required to maintain
PO2 at an
acceptable level.