NURSING DX: Impaired gas exchange related to respiratory secondary

to community-acquired pneumonia
GENERAL GOAL: Optimize respiratory function
BEHAVIORAL OUTCOME OBJECTIVE: Patient will demonstrate
improved gas exchange as evidenced by normal vital signs, absence of
respiratory distress, and increased oxygen saturation.
NURSING INTERVENTION PATIENT RESPONSE

1. Administer prescribed - Patient’s oxygen saturation

respiratory medications
and treatments.
2. Encourage deep breathing
exercises and ambulation
as tolerated.
increased to 97%, no signs
of respiratory distress, and
breath sounds remained
clear after 48 hours.

EVALUATION: Met. The patient demonstrated an increase in oxygen

saturation to 97%, no signs of respiratory distress and clear breath
sounds. The interventions were effective in optimizing respiratory
function.

The third comprehensive medical and nursing management plan

for patient A.C.L. combines various interventions to address her
respiratory distress and underlying community-acquired pneumonia.
From a medical perspective, antiobiotic therapy with Azithromycin
targets the infectious cause, while intravenous fluids including Plain NSS
and Nephrosteril, maintain hydration and electrolyte balance. Nebulizer
treatments and strict aspiration precautions are implemented to alleviate
respiratory symptoms and minimize complications. Ongoing diagnostic
procedures, such as chest X-rays and potential UTS-guided right chest
pigtail insertion, aid in monitoring and intervention. Continuos
monitoring of vital signs and adjustments to medications and fluid levels
are crucial components of medical managemnet, with specialized care
sought from the pulmonary service if respiratory symptoms persist.
Collaboration is emphasized, and blood transfusion may be considered
with vigilant monitoring for adverse events.

Concurrently, nursing management plays a pivotal role in patient care,

encompassing regular respiratory assessments, skin integrity maintenance
through patient turning and application of Calmoseptine, and meticulous
fluid balance monitoring. Patient education on medication compliance
and awareness of worsening respiratory distress signs is prioritized,
accompanied by emotional support to alleviate anxiety. Vigilance for
adverse reactions, particularly during procedures like blood transfusion,
is maintained. The continuous evaluation of the patient’s response to
interventions guides adjustments to the care plan, emphasizing effective
communication between the medical and nursing teams. This
collaborative and dynamic approach aims to achieve positive outcomes
for Patient A.C.L.

1. Impaired gas exchange related to respiratory distress secondary to

pneumonia
The third nursing diagnosis for patient A.C.L. is impaired gas exchange
related to respiratory distress secondary to pneumonia. The underlying
cause of impaired gas exchange in this case is pneumonia, leading to
inflammation and consolidation of lung tissue, compromising the
effective exchange of oxygen and carbon dioxide. The general goal is to
improve gas exchange by addressing the respiratory distress associated
with pneumonia. Pneumonia is recognized as the primary factor
contributing to impaired gas exchange. The infection results in
inflammation and fluid accumulation in the lungs, hindering efficient
oxygenation and causing respiratory distress. The expected outcome is an
improvement in gas exchange, manifested by reduced respiratory distress
and increased oxygen saturation levels. This aligns with the broader goal
of enhancing respiratory function. Identification of signs such as
increased respiratory rate, use as accessory muscles, and labored
breathing associated with pneumonia-induced respiratory distress.
Regular evaluation of pulse oximetry readings, considering the patient’s
oxygen saturation level below the normal range of 86-100%. Elevating
the head of the bed and positioning the patient appropriately to facilitate
improved lung expansion and ease of breathing.

Encouraging the patient to perform deep breathing exercises

independently to enhance chest expansion and optimize oxygen diffusion.
The patient’s response to the interventions should be observed through
decreased respiratory distress, improved oxygen saturation levels, and
enhanced overall comfort during breathing. These positive responses
would indicate successful management of impaired gas exchange related
to pneumonia-induced respiratory distress. Continuous monitoring and
adjustment of interventions are crucial for ongoing assessment and care
refinement.