Nursing Care Plan

NURSING CARE PLAN Nursing Diagnosis Impaired Gas Exchange related to ventilation perfusion imbalance Definition Cues : Subjective
and Objective Subjective: Maglisud man ko ug ginhawa oi, samot na ug mahigda, gaan pajud kaayu akong ulo ,mura kog naglutaw if mubarug ko As verbalized Objective: RR-28 bpm HR- 102 bpm Nasal Flaring Lethargy Tachycardia Specific Objectives Nursing Interventions Rationale Expected Outcomes
Excess or deficit in oxygenation and or carbon dioxide elimination at the alveoli- capillary membrane (This maybe an entity of its own ,but also may be an end result of other pathology with an interrelatedness between airway clearance and /or breathing pattern problems)
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After an hour nursing intervention the patient will : S -demonstrate improved ventilation and adequate oxygenation as evidence by : +Normal Breathing Pattern + Heart Rate with in normal parameters + no nasal flaring K -Verbalized understanding of causative factors and appropriate interventions A -Participate in treatment (such
Independent : -Monitor respiratory rate depth, and effort including use of accessory muscles , nasal, flaring and abnormal breathing patterns -Increased respiratory rate ,use of accessory muscles, nasal flaring, abdominal brathing and a look of panic in the clients eyes may be seen with hypoxia -the presence of crackles and wheezes may alert the muscle to airway obstruction which may lead to or exacerbate existing hypoxia -Changes in behavior and mental status can be early signs of impaired gas exchange .In late stages the client becomes lethargic and somnolent -An oxygen saturation of less than 95% -100 % or a partial pressure of O2 less than 80mmHg
After successfully applying the nursing intervention , the objectives were met as evidenced by : RR-20 HR-80 Absence of nasal flaring Absence of effort during breathing Comfort And Partial pressure of O2 and pulse oximetry in normal parameters
-Auscultate breath sounds every 1-2 hours
=NANDA 11 Ed.
-Monitor the clients behavior and mental status For the onset of restlessness, agitation, confusion, and extreme, lethargy
-Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results
as Breathing exercises and oxygen theraphy
-Observe for cyanosis of the skin, especially note color of the tongue and oral mucous membranes
indicates significant oxygen problems. -central cyanosis of the tongue and oral mucosa is indicated of a serious hypoxia and is medical emergency peripheral cyanosis in the extremities may or may not be serious -accommodate efficient lung expansion and oxygenation -gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation
-Position patient in Semi-Fowlers position with an upright posture at 45 degrees if possible
Collaborative : -If the client has adult respiratory distress syndrome , or difficulty maintaining oxygenation ,consider positioning the client prone with the upper thorax and pelvis supported allowing abd to protrude. -oxygenation levels has been shown to improve in the prone position probably due to decrease dyspnea, shunting, and better perfusion of the lungs
-If the client is acutely dyspneic ,consider having the client lean forward over the bedside table
-learning forward can help decreased dyspnea, possibly because gastric pressure allows better contraction of the diaphragm . This is called the tripod position and is used during times of distress -this technique can help increase sputum clearance and decrease cough spasms. controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. -both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the symphathetic nervous system discharge that accompanies hypoxia. -the hypoxic client has limited reserves
-Help the client deep breathe and performed controlled coughing .Have the client inhale deeply , hold the breath for several seconds , and cough two or three times with the mouth open while tightening the upper abd muscles as tolerated.
-Monitor the effects of sedation and analgesics on the clients respiratory pattern;use judiciary
-Schedule nursing care to provide rest and minimized fatigue
,inappropriate activity can increase hypoxia -watch for signs of psychological distress including anxiety agitation -EBN: one study demonstrated a clear association between hospitalization for COPD and psychological distress -clients with chronic lung problems were described as negative ,helpless, confused and socially obstreperous to family
-assess family role changes and coping ability. Refer the client to medical social services as appropriate for assistance in adjusting to chronic assistance in adjusting to chronic illness.

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What are some signs and symptoms of impaired gas exchange?

What nursing interventions are discussed for impaired gas exchange?

NURSING CARE PLAN Nursing Diagnosis Impaired Gas Exchange related to ventilation perfusion imbalance Definition Cues : Subjective

-Auscultate breath sounds every 1-2 hours

as Breathing exercises and oxygen theraphy

-Position patient in Semi-Fowlers position with an upright posture at 45 degrees if possible

-Schedule nursing care to provide rest and minimized fatigue

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