NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Cues: Impaired Gas Exchange Within 8 hours of nursing 1. Note repiratory rate, 1. This intervention Within 8 hours of nursing
“I’ve seen his O2 r/t Ventilation-Perfusion interventions, the patient depth, use of accessory provides insight into the interventions, the patient
Saturation continues to Imbalance s/t Sepsis will be able to demonstrate mucles, areas of work of breathing and was able to demonstrate
fluctuate since last night, improved ventilation and pallor/cyanosis, and/or adequacy of alveolar improved ventilation and
as well as his other vital adequate oxygenation of general duskiness. ventilation. Since adequate oxygenation of
signs” as verbalized by tissues within normal tachypnea is usually tissues, as evidenced by
the patient’s significant parameters. present to some degree a respiration rate of 20
other. during illness. cpm and an O2
saturation level of 95%.
Objective Cues: 2. Monitor the patient’s pulse 2. To determine
- Under mechanical oximetry and oxygenation levels and - Goal partially met.
ventilation capnography. levels of carbon dioxide
- RR: 28 cpm retention, particularly
- O2 Sat: 88% that he is in mechanical
ventilation.

3. A decreased level in
3. Assess level of consciousness can be an
consciousness and indirect measurement of
mentation changes. impaired oxygenation,
but it also impairs one’s
ability to protect airway,
potentially further
adversely affecting
oxygenation.

4. Elevation or upright
position facilitates
respiratory function and
unloads chest
4. Elevate the head of bed congestion.
and position client
appropriately.
5. This promotes optimal
 chest expansion and
oxygen diffusion.

5. Encourage frequent 6. To provide relief and

position changes. comfort for the patient,
without possibly
overloading oxygen
content.
6. Administer oxygen via
mechanical ventilation
following low-tidal- 7. To facilitate
volume protocol with understanding and
positive end-expiratory thereby promote
pressure. cooperation.

7. Discuss to the significant 8. To assist patient with

other the implication of personal hygiene that is
patient’s alchoholism, in essential in maintaining
relation to his illness. self-esteem and quality
of life.

8. Perform oral care and bed

bath. 9. Since dysphagia is a
common problem in
patients with
mechanical ventilation.

10. For baseline purposes.

9. Assist patient in giving
tube feeding, following
aspiration precaution.

10. Document findings.