Nursing Care Plan

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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 27th, 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 (8th ed.). St. Louis: Mosby Elsevier.


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