ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Impaired Gas August 31, 2022 Independent: After 8 hours of
Data: Exchange 2022: 7am-4pm >Explain to patient the > To better nursing
related to Low ventilation with normal shift disease process and understand the interventions, the
Objective Data: altered perfusion management of symptoms disease, how it was goal was
acquired, how it can
 Presence of alveolar- Short term goal: partially met, as
capillary be prevented. evidenced by:
Capillaries engorged with Within 8 hours of
fine crackles membrane
blood nursing >Assist the patient in a >To promote lung Patient has
all over upon changes due to interventions, the comfortable position, sitting expansion and
pneumonia participated in
auscultation patient will or semi-fowler's decrease respiratory
treatment
disease Stasis
process. participate in effort. regimen within
 Productive treatment regimen
>Monitor respiratory status, > Early recognition level of ability
Alveolocapillary membrane within level of
cough with including rate, pattern of of deterioration in and situation.
breaks down ability and situation
white sputum. respiration, and breath respiratory function
and
sounds will avert further
Vital sign: Alveoli fills with blood and Long term goal: complications.
exudates
 Rr: 18 cpm The patient will be > Demonstrate and help the
> Helps patient
able to maintain a patient perform
prolong expiration
Atelectasis normal respiratory diaphragmatic and pursed
time and decreases air
rate (20-30 breaths lip breathing.
trapping.
per minute) and
Shrunken alveoli breathe without
> Advise the patient to
difficulty. > To prevent
allow the patient to rest and
Impaired gas exchange overexhaustion and
limit activities
reduces oxygen
consumption/
Dependent: demands
> Administer supplemental
oxygen as indicated > Maximizes
available oxygen,
especially while
ventilation is reduced
>Administer intravenous
fluids and medications and >To monitor and
respiratory support as prevent potential
ordered. complications.

(Sources:Handbook
for
Brunner &
Suddarths’ Textbook
of Medical –
Surgical Nursing,
10th Ed. p. 669-670

(Source: Lippincott
Williams and
Wilkins’
Pathophysiology,
p.215)

(Doenges, et. al.,

Nursing Care Plans,
11th Ed., p. 339-340)