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NCP

The patient is unconscious with impaired gas exchange and generalized weakness. Nursing interventions include monitoring vital signs, placing the patient in a semi-Fowler's position, instructing on proper use of a bag valve mask, listening to breath sounds, and adhering to a turning schedule. These measures are intended to ensure adequate ventilation and oxygenation while preventing complications like pneumonia. Evaluation shows the patient demonstrated proper ventilation and oxygenation without respiratory distress.

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Mark Benedict Ocampo Velarde
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584 views

NCP

The patient is unconscious with impaired gas exchange and generalized weakness. Nursing interventions include monitoring vital signs, placing the patient in a semi-Fowler's position, instructing on proper use of a bag valve mask, listening to breath sounds, and adhering to a turning schedule. These measures are intended to ensure adequate ventilation and oxygenation while preventing complications like pneumonia. Evaluation shows the patient demonstrated proper ventilation and oxygenation without respiratory distress.

Uploaded by

Mark Benedict Ocampo Velarde
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT

NURSING DIAGNOSIS Unconscious Impaired Gas With O2 support Exchange @ 3-4 L.min With Bag valve mask Generalized weakness RR: 22 bpm

RATIONALE Oxygen is essential for our living, without O2 we cannot breath. With impairment of gas exchange between o2 and CO2 the patient may experience respiratory acidosis or may become hypoxic that will lead to possible and irreversible respiratory complication.

PLANNING At the end of the shit the patient will be able to demonstrate adequate ventilation and oxygenation of tissue and free of symptoms of respiratory distress.

NURSING INTERVENTION a. monitor VS and record

RATIONALE a. to obtain baseline data of the patient b. to allow greater lung expansion c. to maintain adequate oxygenation to the patient

EVALUATION At the end of the end the patient was able to demonstrate adequate ventilation and oxygenation of tissue free of symptoms of respiratory distress.

b. Place patient on a semi- fowlers position c. Provide instructions to the significant other the proper use of Bag valve mask d. auscultate breath sounds and report for any deviations e. adhere with turning schedule

d. in order to assess the condition of the patient

e. facilitates prevention of atelectasis and pneumonia f. patient is high risk of developing respiratory distress.

f. watch out for signs and symptoms of impending respiratory distress

ASSESSMENT Unconscious Flat on bed Prolonged bed rest

NURSING DIAGNOSIS Risk for impaired skin integrity related to immobility

RATIONALE Unconscious patient is risk for developing skin alterations like pressure ulcers at the buttocks, sacral area and other parts if not prevented this may progress to serious impairment of the skin and may have complications like infection.

PLANNING At the end of the shift, the patient will not develop any pressure ulcer or the signs will be prevented.

NURSING INTERVENTION a. Inspect the skin, noting any signs of pressure ulcers or the like. b. reposition the patient every 2 hours

RATIONALE a. skin is at risk because of impaired peripheral circulation.

EVALUATION At the end of the shift the patient did not develop a pressure ulcer.

b. reduces pressure on tissues, improving circulation c. improves circulation d. excessive dryness or moisture damages skin hastens breakdown.

c. perform back rubbing d. maintain a dry and wrinkle- free bed

ASSESSMENT Unconscious Intubated On O2 support @ 2-3L /min Weak RR:23 bpm

NURSING DIAGNOSIS Ineffective airway clearance r/t increased mucus secretions

RATIONALE Maintaining a patent airway is important because if not so we will not be able to breath properly. In some illness like COPD, there is a mucus clogging on the airway making it difficult to breath spontaneously, thats why some patients requires to be intubated and hooked on a mechanical ventilator or an O2 support. It should be a nursing priority.

PLANNING At the end of the shift the patient will demonstrate adequate ventilation.

INTERVENTION a. Monitor respirations assessing depth and chest movements. b. Elevate head of the bed c. suction as indicated

RATIONALE a. Serves as data

EVALUATION At the end of the shift the patient demonstrated adequate ventilation.

b. promotes greater lung expansion c. mechanically clears the airway and stimulates cough d. facilitates liquefication of mucus secretions e. aids in reduction of bronchospasm

d. increase fluid intake

e. administer medications as prescribed

ASSESSMENT

NURSING DIAGNOSIS Unconscious Impaired Gas With O2 support Exchange @ 3-4 L.min With Bag valve mask Generalized weakness RR: 22 bpm

RATIONALE Oxygen is essential for our living, without O2 we cannot breath. With impairment of gas exchange between o2 and CO2 the patient may experience respiratory acidosis or may become hypoxic that will lead to possible and irreversible respiratory complication.

PLANNING At the end of the shit the patient will be able to demonstrate adequate ventilation and oxygenation of tissue and free of symptoms of respiratory distress.

NURSING INTERVENTION a. monitor VS and record

RATIONALE a. to obtain baseline data of the patient b. to allow greater lung expansion c. to maintain adequate oxygenation to the patient

EVALUATION At the end of the end the patient was able to demonstrate adequate ventilation and oxygenation of tissue free of symptoms of respiratory distress.

b. Place patient on a semi- fowlers position c. Provide instructions to the significant other the proper use of Bag valve mask d. auscultate breath sounds and report for any deviations e. adhere with turning schedule

d. in order to assess the condition of the patient

e. facilitates prevention of atelectasis and pneumonia f. patient is high risk of developing respiratory distress.

f. watch out for signs and symptoms of impending respiratory distress

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