NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired Gas Exchange related Within 4 hours of nursing 1. Place the client in a Semi-Fowler position promotes After 4 hours of nursing
Patient stated he “doesn’t feel to altered oxygen supply interventions, the patient will be semi-Fowler’s position. lung expansion and decreases interventions, the patient
good,” explaining that he has (obstruction of airways by able to maintain optimal gas airway collapse, dyspnea, and maintained optimal gas
missed the last week of school, secretion) exchange as evidenced by breath work through gravity. exchange as evidenced by
doesn’t have any energy, is  oxygen saturation of  oxygen saturation of
coughing more, and is having a 90% or greater; 2. Maintain a patent Preventing complications of 90% or greater;
hard time breathing.”  arterial blood gasses airway. respiratory failure.  arterial blood gasses
(ABGs) within the (ABGs) within the
Objectives: client’s usual range; 3. Monitor respiratory and There will be an increase in the client’s usual range;
 color pale pink with  relaxed breathing; heart rate for any respiratory and heart rate as a
 relaxed breathing;
bluish tinged nail beds  baseline heart rate; changes. way of compensation for early
 rhonchi noted  alert response hypoxia.  baseline heart rate;
 alert response
throughout mentation and;
 thorax has a barrel chest  no further deterioration 4. Monitor transcutaneous Chronic hypercarbia can be mentation and;
 no further deterioration
appearance in the level of carbon dioxide as present in clients with moderate
 appears thin consciousness. ordered. to severe cystic fibrosis lung in the level of
consciousness.
disease; increasing levels can
Vital Signs indicate the progression of acute
RR = 28 breaths/min (somewhat infection and pending
labored) respiratory failure.
Temp = 38.8° C (oral)
Weight = 30 kg 5. Monitor vital signs, Increased PaCO2 indicates
SaO2 = 88% arterial blood gases impending respiratory failure
(ABGs), and pulse during asthmatic. Tachycardia,
oximetry to detect / dysrhythmias, and changes in BP
prevent hypoxemia. may indicate systemic
hypoxemia effects on cardiac
function
6. Motivate exercise
appropriate physical Physical exercise is often
condition of the patient. effective to clear accumulated

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 lung secretions and to improve
endurance exercise capacity
before experiencing dyspnea.

7. Provide for adequate

rest between activities Activity increases oxygen needs
during the day, with a and should be paced
minimal nighttime appropriately to avoid fatigue.
interruption in sleep.

8. Provide supplemental
oxygen according to the Occurrence / respiratory failure
provisions / that would require effort dating
requirements. Monitor lifesaving action. Supplemental
patients closely for oxygen administration can fix /
carbon dioxide narcosis prevent worsening hypoxia.
due to oxygen is danger
of oxygen therapy in
patients with chronic
lung disease.

9. Assess skin color for

development of Lack of oxygen delivery to the
cyanosis, especially tissues will result in cyanosis.
circumoral cyanosis. Cyanosis needs treated
immediately as it is a late
development in hypoxia.
10. Assess for changes in
respiratory status such Client will adapt their breathing
as cyanosis, pallor, pattern over time to facilitate gas
changes in the level of exchange. Abnormalities may
consciousness, labored indicate respiratory compromise,
breathing and hypercarbia, or hypoxia.
tachypnea.

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 This study source was downloaded by 100000806518079 from CourseHero.com on 10-02-2022 07:34:41 GMT -05:00
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