Nursing Care Plan


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Medical Diagnoses: Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus.


1.      Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus.

·         O2 Sats 74% on 2L

·         SOB and WOB

·         Decreased BP

·         Anxiety and Lethargy

3. Acute pain related to fractured left femoral neck.

·         Lethargy and anxiety

·         WOB increased RR 26

·         Incision site

·         fatigue

2.  Ineffective Breathing Pattern related to obstruction.

·         O2 Sats 74% on 2L

·         SOB and WOB

·         Anxiety and Lethargy

·         increased RR 26

·         fatigue

4. Anxiety related to the impending doom that pt. is experiencing

·         Noted by PT

·         SOB

·         WOB increased RR 26

Chief Complaint: A 78 year old white male fell at home and fractured his left femoral neck and had Open Reduction Internal Fusion surgery to repair fracture.

 

Priority Assessment: Monitor vital signs and pain level.  Monitor LOC and mobility.  Practice and educate about turn, cough, deep breathe and ambulation.  Monitor drainage and incision site. .  Practice standard precautions to help prevent infection. Monitor blood glucose levels and labs.

5. Acute Confusion related to decreased supply of oxygen to the brain.

·         O2 Sats 74% on 2L

·         Noted by PT and APRN

·         Anxiety and Lethargy

·         fatigue

7. Impaired physical mobility related to fractured left femoral neck.

·         Lethargy and anxiety

·         WOB increased RR 26

·         Incision site

6. Fatigue related to fractured left femoral neck and dyspnea.

·         Lethargy and anxiety

·         WOB increased RR 26

·         Incision site

·         O2 Sats 74% on 2L

·         SOB and WOB

8. Risk for injury related to breathing pattern and fractured left femoral neck.

·         Lethargy and anxiety

·         WOB increased RR 26

·         O2 Sats 74% on 2L

·         SOB and WOB

·         fatigue


NANDA Diagnostic Statement: Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus as evidence by dyspnea and abnormal O2 sats 74% on 2L

Behavioral Outcome / Goal: Patient will maintain optimal gas exchange as evidenced by normal arterial blood gases (ABGs),  pulse oximetry results within normal range, usual mental status and normal respiration rate (by a specific date and time).


Nursing Interventions:

 

1.      Frequently assess respiratory status including rate, depth, effort, lung sound and SPO2 at least every 2-4 hours.

 

2.      Assess the mental status of the client (changes in orientation and behavior). Assess for increased hypoxia.

 

3.      Analyze lab work including ABG’s and hemoglobin and hematocrit.

 

4.      Position the patient in high fowler’s position and collaborate with the health-care team regarding prone positioning.

 

5.      Administered oxygen as ordered by the doctor.

 

6.      Provide teaching regarding respiratory exercises.

 

7.      Maintain bed rest.

 

8.      Turn every 2 hours on (odd/even) hour.

Rationale:

 

1.       Impaired ventilation affects gas exchange and worsens hypoxemia (Tachypnea, dyspnea). SPO2 can be used as a non-invasive method to monitors oxygen saturation. (Cox’s Clinical pg: 294)

2.        Restlessness is an early sign of hypoxia .Hypoxemia often causes confusion and agitation. (Cox’s Clinical pg: 350)

3.       Will provide integral information to determine deficits in capacity and effect of oxygen delivery. (Cox’s Clinical pg: 347)

4.       Facilities chest expansion and promotes gas exchange and with alveolar recruitment. (Cox’s Clinical pg: 347)

5.       To improve oxygenation.

6.       Promotes alveolar open. (Cox’s Clinical pg 347)

7.       Bed rest reduces metabolic demands for oxygen. (Cox’s Clinical pg: 347

8.       Position changes modify ventilation- perfusion relationships and enhance gas exchange. (Cox’s Clinical pg: 347)__________________________

Client Response:

Summarize impressions of client progress toward outcomes / problem resolution

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