NURSING CARE PLAN 1 Impaired gas exchange

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired gas Within 2 hours Independent: After 2 hours of

“Hindi ako exchange of rendering rendering proper
makahinga ng related to proper nursing  Monitor the color of the  Peripheral cyanosis may nursing
mabuti. Parang altered oxygen interventions the skin and mucous be evident with interventions the
hinahabol ko ang supply as patient will be membrane hypoxemia. Central patient was able
paghinga ko.” As evidenced by able to to demonstrate
cyanosis involving the
verbalized by the shortness of demonstrate improved
patient. breath. improved mucosa may indicate ventilation and
ventilation and further reduction of adequate
Objective data: adequate oxygen levels oxygenation by
Scientific oxygenation by  Monitor the patient’s the patient
 lungs has Explanation: the patient  To create a baseline set eliminating
vital signs, especially the
scattered Gas is eliminating dyspnea. Goal
respiratory rate and of observations, and to
crackles exchange dyspnea met.
between the depth. Auscultate the monitor changes in the
upon lungs and monitor for vital signs as the patient
alveoli
auscultati and the abnormal breath sounds. receives interventions.
on pulmonary
 Weak in capillaries via  Maintain oxygen therapy
appearan diffusion of  To maximize oxygen
through non Rebreather
ce oxygen supply.
and carbon mask
dioxide
Vital signs occurs
 Determine oxygenation
taken: passively.  Evaluate pulse oximetry
According to levels of carbon dioxide
T- 36.5 ⸰C their and cardiac rhythm. retention.
BP: 100/72 concentration
mmHg differences  Check for any alterations  Changes are due to low
RR: 24 cpm must be
in level of consciousness oxygen delivery to the
HR: 96 bpm maintained by
SPO2: 84% ventilation of brain.
the
Sodium- 125 alveoli and
mEq/L perfusion od  Encourage adequate rest
the  To prevent excessive
periods oxygen usage from
ABG results pulmonary
PO2-65 mmHg capillaries. activities.
pH 7.48  Reposition the patient by
PCO2 32 mmHg Reference: elevating the head of the
Brunner &  This improves delivery
bed of the and encourage of oxygen in the airways
Suddarth's
textbook of the patient to sit in an and for maximized lung
medical upright position. expansion.
surgical
nursing (11th
edition  Encourage lip breathing  Reduce shortness of
exercises breath and risk for
airway collapse

Dependent:

 Monitor blood chemistry  To check for respiratory

and arterial blood gases acidosis and hypoxemia
(ABG). that are evidenced by
decreasing PaCO2 and
PaO2
 NURSING CARE PLAN 2 Ineffective breathing

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective Short term: Independent: Independent:

Nahihirapan breathing Short term:
akong huminga pattern related Within 30mins –  Establish rapport with
nurse” as to decreased 1 hour of the patient and  To gain their trust and After 30mins – 1
verbalized by the lung expansion rendering significant other. cooperation. hour of rendering
patient as evidenced nursing nursing
by shortness of interventions, the interventions, the
breath patient will be  Monitor quality, depth,  To detect early signs of patient was able to
able to establish pattern, and rate of respiratory distress. establish a relaxed
Objective data: Scientific relaxed breathing respiration, use of breathing pattern.
Rationale: pattern. accessory muscles, and
- Audible of dyspnea. GOAL MET!
scattered When the
crackles breathing
pattern is  Auscultate breath sounds  To monitor the presence
ineffective, the using a stethoscope . of abnormal breath
-Vital signs body will sounds such as crackles,
taken: likely not get wheezing, and rhonchi.
T- 36.5 ⸰C enough oxygen
BP: 100/72 to the cells.
 Provide a quiet  To improve energy
mmHg Respiratory
RR: 24 cpm failure may be environment that is reserve and prevent
HR: 96 bpm correlated with conducive to rest and excessive usage of
SPO2: 94% variations in sleep. oxygen by the body.
respiratory
rate, abdominal
and thoracic
patterns.  Place the patient in a
 semi-fowler’s position
 This position permits
maximum lung excursion
 Demonstrate breathing and chest expansion.
techniques to the patient.
Teach patient about
pursed-lip breathing,  Breathing techniques
abdominal breathing, greatly improve
performing relaxation ventilation and increase
techniques the relief of the patient
from dyspnea
 Provide small frequent
feedings to the patient
 To prevent abdominal
distention which can
interfere with breathing
and increased risk of
Dependent:
aspiration.
 Administered oxygen as
ordered
 Supplemental oxygen
helps reduce hypoxemia
Collaborative:
and relieve respiratory
distress
 Refer to a respiratory
therapist.

 To further help patients

by providing appropriate
respiratory care and
management.