Impaired Gas Exchange, Decreased functional lung tissue

Nursing Care Plan

Medical Diagnoses: Impaired Gas Exchange, Decreased functional lung tissue

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Pt stated that she feels short of breath

Pt states that she is unable to walk farther than the bathroom or chair without feeling winded.

During a conversation, pt stated “I need to stop talking for a minute to catch my breath.”

Objective

Diagnosis of pulmonary hypertension

Pt chart states that she has abnormal arterial blood gases

Pt chart states that she has abnormal arterial pH

Pt demonstrates dyspnea

Evidence of crackles in the pt’s left lung

O2 gauge set on 6 liters, nasal cannula



Problem

Impaired Gas Exchange

Long Term:

Pt will demonstrate clear lung fields by discharge.

* Encourage deep breathing and coughing exercises

Rationale:

“Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective.” (Ackley & Ladwig, 2008, p. 389)

*Help client eat frequent small meals and use dietary supplement as necessary.

Rationale:

“Improved nutrition can help increase muscle aerobic capacity and exercise tolerance.” (Ackley & Ladwig, 2008, p. 389)

ü





Goal met. Pt demonstrated clear lung fields and no evidence of crackles upon assessment. Pt stated she felt like she was able to breath better and she stated that she was experiencing a much m ore productive cough than before. Pt said she thought the breathing exercises really helped out.

Continue interventions as listed. Continue to encourage deep breathing and coughing exercises. Continue to encourage small meals and needed supplements.

R/T

Decreased functional lung tissue

Short Term:

Pt will demonstrate improved ventilation by the end of this shift.

*Auscultate breath sounds every two hours or PRN.

Rationale:

“… lung sounds may be diminished or distant with air trapping.” (Ackley & Ladwig, 2008, p. 388)

*Monitor respiratory rate, depth, and effort every two hours or PRN.

Rationale:

“Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client’s eyes may be seen with hypoxia.” (Ackley & Ladwig, 2008, p. 388)

*Monitor oxygen saturation by pulse oximetry every two hours or PRN.

Rationale:

“An oxygen saturation of less than 90% or a PaO2 of less than 80 mm Hg indicates significant oxygenation problems.” (Ackley & Ladwig, 2008, p. 388)

*Encourage deep breathing and coughing exercises.

Rationale:

“Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective.” (Ackley & Ladwig, 2008, p. 389)

ü

Goal met. Pt demonstrated improved ventilation upon assessment. Pt stated that she felt like she could breathe much better by the end of shift. She stated she felt like she was having a much more productive cough and getting the mucus up better. Pt’s O2 sat also remained at 96% and did not drop throughout the shift. The nurse stated that the pt’s O2 sat today, was better than it had been since she was admitted on Month 27^th, Year.

Continue interventions as listed. Continue to auscultate breath sounds, monitor respiratory rate, and O2 sat every two hours or PRN. Continue to encourage deep breathing and coughing exercises.

AEB



Chart states abnormal ABGs

Chart states abnormal arterial pH

Pt states that she is winded with little activity.

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*I = Implementation. Check those interventions/actions/orders that were implemented

References

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8^th ed.). St. Louis: Mosby Elsevier.

Return to Table of Contents

Assessment	Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/Objectives	Nursing Interventions/Actions/Orders and Rationale	*I	Evaluation
					Goals	Interventions
Subjective Pt stated that she feels short of breath Pt states that she is unable to walk farther than the bathroom or chair without feeling winded. During a conversation, pt stated “I need to stop talking for a minute to catch my breath.” Objective Diagnosis of pulmonary hypertension Pt chart states that she has abnormal arterial blood gases Pt chart states that she has abnormal arterial pH Pt demonstrates dyspnea Evidence of crackles in the pt’s left lung O2 gauge set on 6 liters, nasal cannula	Problem Impaired Gas Exchange	Long Term: Pt will demonstrate clear lung fields by discharge.	* Encourage deep breathing and coughing exercises Rationale: “Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective.” (Ackley & Ladwig, 2008, p. 389) *Help client eat frequent small meals and use dietary supplement as necessary. Rationale: “Improved nutrition can help increase muscle aerobic capacity and exercise tolerance.” (Ackley & Ladwig, 2008, p. 389)	ü	Goal met. Pt demonstrated clear lung fields and no evidence of crackles upon assessment. Pt stated she felt like she was able to breath better and she stated that she was experiencing a much m ore productive cough than before. Pt said she thought the breathing exercises really helped out.	Continue interventions as listed. Continue to encourage deep breathing and coughing exercises. Continue to encourage small meals and needed supplements.
	R/T Decreased functional lung tissue	Short Term: Pt will demonstrate improved ventilation by the end of this shift.	Auscultate breath sounds every two hours or PRN. Rationale: “… lung sounds may be diminished or distant with air trapping.” (Ackley & Ladwig, 2008, p. 388) Monitor respiratory rate, depth, and effort every two hours or PRN. Rationale: “Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client’s eyes may be seen with hypoxia.” (Ackley & Ladwig, 2008, p. 388) Monitor oxygen saturation by pulse oximetry every two hours or PRN. Rationale: “An oxygen saturation of less than 90% or a PaO2 of less than 80 mm Hg indicates significant oxygenation problems.” (Ackley & Ladwig, 2008, p. 388) Encourage deep breathing and coughing exercises. Rationale: “Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective.” (Ackley & Ladwig, 2008, p. 389)	ü	Goal met. Pt demonstrated improved ventilation upon assessment. Pt stated that she felt like she could breathe much better by the end of shift. She stated she felt like she was having a much more productive cough and getting the mucus up better. Pt’s O2 sat also remained at 96% and did not drop throughout the shift. The nurse stated that the pt’s O2 sat today, was better than it had been since she was admitted on Month 27^th, Year.	Continue interventions as listed. Continue to auscultate breath sounds, monitor respiratory rate, and O2 sat every two hours or PRN. Continue to encourage deep breathing and coughing exercises.
	AEB Chart states abnormal ABGs Chart states abnormal arterial pH Pt states that she is winded with little activity.