PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: Patient J. Age & Gender: 77 y/o Male Chief Complaint: Dyspnea, Fatigue, and Nausea Name of Student Nurse: Jhon Kenneth M. Juguilon
Birthday: January 26, 1946 Admitting Diagnosis: Impaired Gas Exchange Level/block/group: UP-FB2-BSN1-15
Address: Dagupan City, Pangasinan Hospital/area: Medical Centrum Dagupan
Date of Confinement: March 24, 2023 Clinical Instructor: Alliah Grace N. Garcia
Date: March 24, 2023

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Excess or deficit in oxygenation Within the 8-hour Independent: To prevent hypoxemia and Within the 8-hour
and/or carbon dioxide elimination at shift, the client will Administer oxygen as needed. maintain an oxygen saturation shift, the patient
Subjective: the alveolar-capillary membrane. be able to: above 95%. was free from the
“ The patient said that he Monitor oxygen saturation and signs and
experienced shortness of Short Term Goal: arterial blood gases as needed. An SPO2 below 90% or a respiratory distress
breath, fatigue, and The patient will be partial pressure of oxygen less and his oxygen
nausea. And he free from the signs Dependent: than 80 mmHg indicates severe saturation is at
developed cold last week and respiratory Administer antibiotics as prescribed respiratory dysfunction and 96%. And his
and does not seem to be distress and his by the Physician. should be treated promptly temperature is
improving.” oxygen saturation 37.2 °C .
will be remain higher Administer bronchodilators or To prevent and to control the
Objective: than 96%. And his inhaled steroids. symptoms. The patient is at
temperature will be ease and having a
Diaphoretic, Weak down to 37.5 0°C Collaboration: Inhaled bronchodilators work normal breathing
cough, Fast, Shallow within the shift. Refer to a specific supplier for by relaxing the airway muscles, pattern.
Breath, Crackles sound in supplemental oxygen or necessary and inhaled steroids work by
the Lungs. Long Term Goal: respiratory devices. decreasing inflammation in the
BP: 110/70 mmHg The patient will airway.
PR: 114 bpm finish the full course
RR: 28 bpm of antibiotics as To reach independence.
Temp: 38.5 °C prescribed by the
O²2 Sat: 90 % Physician.
 NURSING DIAGNOSIS EXPLANATION OF THE PROBLEM
Impaired gas exchange A patient that is having a impaired
related to alveolar- gas exchange feels shortness of
capillary membrane breath (dyspnea), having trouble on
changes as evidenced by inspiration and expiration. As the
shortness of breath, low patient experienced, he has weak
SPO2, and bacteria found cough and shallow breathing that can
in sputum culture. be trigger to other conditions.