UNIVERSITY OF SAN JOSE-RECOLETOS COLLEGE OF NURSING

NURSING CARE PLAN

Name: Age: . Sex: . Religion:

Occupation: Status: Date of admission: .

Assessment

Nursing Diagnosis
Impaired Gas Exchange related to AlveolarCapillary Membrane Changes and respiratory fatigue secondary to Pleural Effusion

Scientific Analysis

Objectives

Nursing Intervention

Rationale >To gain pt./SOs trust and cooperation >To obtain baseline data >To assess for rapid or shallow respiration that occur because of hypoxemia and stress

Evaluation After 3 days of nurseclient intervention the patient was able to: a. Demo nstrat e hourly deep breath ing exerci

Values Integration
Don't cry because it's over, smile because it happened.

Perfusion to the After 3 days of nurse- >Establish rapport myocardium is client intervention the often impaired patient will able to: with left >Monitor and record ventricular failu a. Demonstrate re, and hourly deep vital signs especially with breathing cardiac exercises and hypertrophy. As cough sessions >Monitor respiratory the amount if needed. of blood b. Establish the rate, depth and rhythm ejected from importance of the left daily ventricle pulmonary diminishes, exercise

hypostatic pressure builds in the pulmonary venous system and results in fluid-filled alveoli and pulmonary congestion. Source:
http://www.scrib d.com/doc/25327 807/Ncp-forimpaired-gasexchange

>Assess pts general condition

>To note for etiology precipitating factors that can lead to impaired gas exchange >To evaluate degree of compromise

>Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus

ses and cough sessio ns if neede d. b. Establi sh the import ance of daily pulmo nary exerci se.

>Elevate head of the patient >Note for presence of cyanosis

>To enhance lung expansion >To assess inadequate systemic oxygenation or hypoxemia >To promote optimum chest expansion

>Encourage frequent position changes and deep-breathing exercises

>Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation >Review laboratory results >Provide health teaching on how to alleviate pts condition >Administer prescribed medications as ordered

>To correct/ improve existing deficiencies

>To determine pts oxygenation status >To empower SO and pt

>For the pharmacological management of the patients condition