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
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Problem
Impaired Gas Exchange
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Long Term:
Pt will demonstrate clear lung fields by discharge.
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* 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)
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ü
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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.
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Continue interventions as listed. Continue
to encourage deep breathing and coughing exercises. Continue to encourage small
meals and needed supplements.
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R/T
Decreased functional lung tissue
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Short Term:
Pt will demonstrate improved ventilation by the end of this shift.
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*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)
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ü
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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.
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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.
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