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    Nursing Care Plan Impaired Gas Exchange

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    cuicuita
    This document contains a nursing assessment, diagnosis, plan of care, implementation, and evaluation for a 75-year-old female patient diagnosed with aspiration pneumonia who has a tracheostomy. The patient has an impaired gas exchange related to a ventilation-perfusion imbalance as evidenced by abnormal arterial blood gases. The short-term goal is for the patient to maintain normal arterial blood gases and oxygen saturation during their shift. The long-term goal is for the patient to be weaned off the ventilator and maintain oxygen saturation above 97% on room air before discharge. The plan lists nine nursing actions to address the patient's needs with rationales provided. The evaluation found the short-term goal was met as the patient's arterial blood

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    Nursing Care Plan Impaired Gas Exchange

    Uploaded by

    cuicuita
    16K views1 page
    This document contains a nursing assessment, diagnosis, plan of care, implementation, and evaluation for a 75-year-old female patient diagnosed with aspiration pneumonia who has a tracheostomy. The patient has an impaired gas exchange related to a ventilation-perfusion imbalance as evidenced by abnormal arterial blood gases. The short-term goal is for the patient to maintain normal arterial blood gases and oxygen saturation during their shift. The long-term goal is for the patient to be weaned off the ventilator and maintain oxygen saturation above 97% on room air before discharge. The plan lists nine nursing actions to address the patient's needs with rationales provided. The evaluation found the short-term goal was met as the patient's arterial blood

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    Nursing Care Plan Impaired gas exchange

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    This document contains a nursing assessment, diagnosis, plan of care, implementation, and evaluation for a 75-year-old female patient diagnosed with aspiration pneumonia who has a tracheostomy. The patient has an impaired gas exchange related to a ventilation-perfusion imbalance as evidenced by abnormal arterial blood gases. The short-term goal is for the patient to maintain normal arterial blood gases and oxygen saturation during their shift. The long-term goal is for the patient to be weaned off the ventilator and maintain oxygen saturation above 97% on room air before discharge. The plan lists nine nursing actions to address the patient's needs with rationales provided. The evaluation found the short-term goal was met as the patient's arterial blood

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    16K views1 page

    Nursing Care Plan Impaired Gas Exchange

    Uploaded by

    cuicuita
    This document contains a nursing assessment, diagnosis, plan of care, implementation, and evaluation for a 75-year-old female patient diagnosed with aspiration pneumonia who has a tracheostomy. The patient has an impaired gas exchange related to a ventilation-perfusion imbalance as evidenced by abnormal arterial blood gases. The short-term goal is for the patient to maintain normal arterial blood gases and oxygen saturation during their shift. The long-term goal is for the patient to be weaned off the ventilator and maintain oxygen saturation above 97% on room air before discharge. The plan lists nine nursing actions to address the patient's needs with rationales provided. The evaluation found the short-term goal was met as the patient's arterial blood

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    ASSESSMENT*

    DATA BASE sorted


    & grouped for
    EACH nursing
    diagnosis)
    Have six of these
    Can be either s or o
    O
    Crackles on lung
    fields
    O
    Skin color pale
    O
    ph 7.56
    O
    HCO3 36.4 mEq/L
    O
    PaO2 56.7 mm Hg
    O
    SpO2 88%

    ANALYSIS*
    Statement
    3 part NANDA
    NURSING
    DIAGNOSIS
    Analysis: This is a
    75 year old female
    dx aspiration
    pneumonia and with
    a tracheostomy.

    Impaired gas
    exchange r/t
    ventilationperfusion imbalance
    AEB abnormal
    arterial blood gases

    PLAN
    CLIENT
    Short term Goal
    Long term Goal

    STG: The client


    will maintain
    normal ABGs
    and O2 sats
    during shift
    LTG: The client
    will be weaned
    off the vent and
    able to maintain
    O2 sats above
    97% room air
    before discharge
    from unit.

    IMPLEMENTATION
    (NURSING ACTIONS, including teaching)
    RATIONALE
    NUMBER THEM

    1. Assess respiratory rate, depth and ease of


    respiration. R:Respiration exceeds 30 breaths/min, a
    cardiovascular or respiratory alteration exists.
    2. Auscultate breath sounds every 1 to 2 hours. R:
    Crackles may alert the nurse for airway obstruction.
    3. Assess for cyanosis of the skin. R: Central
    cyanosis of the tongue and oral mucosa is indicative
    of hypoxia.
    4. Position the client in a semirecumbent position
    with the HOB at 30 to 45 degree angle. R: To
    decrease aspiration of gastric, oral and nasal
    secretions.
    5. Suction tracheobronchial secretions PRN. R:
    Retention of secretions leads to hypoxia and promote
    infection.
    6. Monitor O2 saturation. R: O2 sat less than 90%
    indicates oxygenation problems.
    7. Teach the client about energy conservation. R:
    Alternating rest periods with activity is helpful to
    improve respiratory function.
    8. Teach the client about identifying and avoiding
    situations that exacerbates impairment of gas
    exchange. R: Irritants decrease the clients
    effectiveness in accessing oxygen during breathing.
    9. Teach the client and family to keep temperature
    above 68F and to avoid cold weather. R: Cold air
    temperatures causes constriction of the blood
    vessels, which impairs the clients ability to absorb
    oxygen.

    EVALUATION of
    STG/LTG GOALS
    AND EACH
    Nursing ACTION
    IMPLEMENTATI
    ON
    CORRELATE
    Numbering

    1. ABGs, O2
    sats WNL.
    STG met.
    2. LTG unable
    to evaluate this
    time

    RETHINK REPLAN REDO


    REWRITE the Implementations and
    tell if will keep in POC, Revise it, or
    Delete. Tell who will do it.
    This is like a shift report.

    1. Registered nurse continue to


    assess respiratory rate, depth and
    ease of respiration.
    2. Registered nurse continue to
    auscultate breath sounds every 1 to 2
    hours.
    3. Registered nurse continue to
    assess for cyanosis of the skin. 4.
    Position the client in a
    semirecumbent position with the
    HOB at 30 to 45 degree angle.
    5. Registered nurse continue to
    suction tracheobronchial secretions
    PRN.
    6. Registered nurse continue to
    monitor O2 saturation
    7. Registered nurse continue to teach
    the client about energy conservation.
    8. Registered nurse continue to teach
    the client about identifying and
    avoiding situations that exacerbates
    impairment of gas exchange.
    9. Registered nurse continue to teach
    the client and family to keep
    temperature above 68F and to avoid
    cold weather.

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