College of Allied Health Sciences N.C.

P
Nursing Program Nursing Care Plan

Name of Patient: Patient M. Date of Admission: 10/6/2022 Age: 26 Sex: Female Civil Status: N/A
Chief Complaint: 48-Hour history of progressive dyspnea, Generalized edema, and Left lower chest pain with non-productive cough
Attending Physician: Dr. Magallona

Date / Cues Nursing Goals & Interventions Rationale Evaluation

Time Diagnosis Objectives
October 6, Subjective/s: Impaired Gas Within 8 hours if INDEPENDENT: INDEPENDENT: GOAL MET
2022 - The patient exchange r/t nursing intervention, A. Assist the patient in A. To facilitate lung
@3:00 pm verbalized, accumulation of the patient will be finding a comfortable expansion and reduce After 8 hours of
fluid in pleural able to: position (e.g., semi- the work of breathing. nursing intervention
“I experienced space aeb Fowler's) that the patient able to:
fluid retention dyspnea, - Demonstrate optimizes lung
that went way elevated RR, improved gas expansion and - The patient's
beyond the o2sat of 92%, exchange as encourages deeper oxygen saturation
usual hormone and presence of evidenced by an breathing. has increased to
fluctuations or pleural effusion. increase in oxygen 95%
indulgence in saturation to ≥ 95%.
overly salty Scientific basis: B. Respiratory - The patient's
B. Encourage the exercises help in lung
food.” The nursing - The patient's respiratory rate has
patient to perform expansion, prevent
diagnosis of respiratory rate will decreased and
“I presented to "Impaired Gas decrease to within deep-breathing atelectasis (lung remained within the
the emergency Exchange" is the normal range exercises, coughing, collapse), and normal range (18
department supported by (e.g., 12-20 breaths and spirometry as promote the cpm)
with a 48-hour the scientific per minute) appropriate. clearance of
history of basis that - Reported
respiratory secretions.
progressive pleural effusion, - Report a reduction decreased in
dyspnea, characterized by in dyspnea and symptoms such as
generalized the increased comfort C. Educate the patient
and caregivers on the C. Educating the shortness of breath
edema and left accumulation of during breathing, and improved
lower chest fluid in the indicating improved importance of proper patient and caregivers comfort.
pain with a pleural space, gas exchange and positioning and offer on proper positioning
non-productive restricts lung lung function. guidance on activities and respiratory
cough.” expansion and that may improve gas techniques like
exchange such as
College of Allied Health Sciences N.C.P
Nursing Program Nursing Care Plan

alters the diaphragmatic diaphragmatic and

Objectives: mechanics of breathing and pursed- pursed-lip breathing
- RR: 34 cpm respiration. This lip breathing can be helps optimize lung
- HR: 144 bpm leads to particularly helpful. mechanics, increase
- O2sat: 92% impaired
oxygenation, and
ventilation and
reduce the work of
ABG Result: gas exchange in
- Metabolic the alveoli, breathing, leading to
acidosis: causing reduced improved gas
pH: 7.134 oxygen uptake exchange and overall
HCO3: 6 and carbon respiratory function.
dioxide removal.
- (+) Pleural The
effusion compromised
lung function, DEPENDENT:
often associated A. Administer oxygen DEPENDENT:
with conditions @3L per minute via A. Helps raise the
such as heart nasal canulla patient's blood oxygen
failure or saturation levels (SpO2)
inflammatory to a normal range
diseases like (typically 95% or higher)
Systemic Lupus to ensure that cells
Erythematosus receive an adequate
(SLE), further supply of oxygen for
exacerbates the metabolism and organ
impairment, function.
ultimately
resulting in
decreased B. Administer
arterial Furosemide as per B. To treat the fluid
oxygenation accumulation in the
physician’s order.
levels pleural space of the
COLLABORATIVE:
(hypoxemia) patient.
A. Collaborate with a
and an elevated COLLABORATIVE:
College of Allied Health Sciences N.C.P
Nursing Program Nursing Care Plan

partial pressure physician or A. This procedure can

of carbon respiratory therapist help drain excess fluid
dioxide to perform from the pleural
(hypercapnia). thoracentesis or space, relieving
Consequently,
chest tube insertion pressure on the lungs
addressing the
as appropriate for and improving gas
effusion and
optimizing lung the patient's exchange.
function are condition.
essential to
alleviate
impaired gas
exchange in
affected
individuals.

https://
onlinelibrary.wil
ey.com/doi/
abs/
10.1002/978111
8702864.ch7