Impaired Gas Exchange

Impaired Gas Exchange

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Anesthesia
(_) Allergic response
(_) Altered level of consciousness
(_) Anxiety
(_) Aspiration
(_) Decreased lung compliance
(_) Edema of tonsils, adenoids, sinuses
(_) Excessive or thick secretions
(_) Fear
(_) Immobility
(_) Improper positioning		 (_) Infection
(_) Loss of lung elasticity
(_) Medication
(_) Neuromuscular impairment
(_) Obstruction
(_) Pain
(_) Smoking
(_) Surgery
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(Must be present)		 (_) Dyspnea on exertion.
Minor:
(May be present)		 (_) Tendency to assume a three-point position (bending forward while supporting self by placing one hand on each knee).
(_) Pursed lip breathing with prolonged expiratory phase.
(_) Increased anteroposterior chest diameter, if chronic.
(_) Lethargy and fatigue.
(_) Increased pulmonary vascular resistance (increased pulmonary artery/right ventricular pressure).
(_) Decreased oxygen content, decreased oxygen saturation, increased PCO2.
(_) Cyanosis.

Date &
Sign.		 Plan and Outcome
[Check those that apply]		 Target
Date:		 Nursing Interventions
[Check those that apply]		 Date
Achieved:
The patient will:

(_) Demonstrate optimal gas exchange as permitted by clinical condition A.E.B.:

  • absence of cyanosis
  • ABG's are within acceptable limits.

(_) Other:

 (_) Assess color, respiratory rate and depth, effort, rythm q___.

(_) Check for breath sounds q___.

(_) Report ABG's that deviate from patient's baseline.

(_) Position to facilitate optimum breathing patterns:

  • HOB elevated ___ deg.
  • turn q____ hrs.
  • other:

(_) Cough and deep breath.

(_) Suction q___ hrs.

(_) Increase actibity as tolerated to facilitate diaphragm excursion. eg:
________________________
________________________

(_) Encourage fluid intake to decrease viscosity of secretions (when indicated).

(_) Explore with patient potential etiological factors contributing to impaired gas exchange and provide appropriate health teaching. (Discharge Plan)

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Friday, May 16, 2008 | Labels: |

This entry was posted on Friday, May 16, 2008 and is filed under care plan . You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

 

0 comments:

Post a Comment

Subscribe to: Post Comments (Atom)

OUR FACEBOOK FANPAGE