Nursing Diagnosis : Impaired gas exchange related to hypoventilation
Goal: after nursing interventions, clients showed improvement in gas exchange.
Expected outcomes:
- Clients will show the results of blood gas analysis within the range of normal limits.
- The skin will be free of symptoms of respiratory distress.
- Clients will notice improvement in mental status.
Intervention and rasioanal:
1). Note the depth of breathing frequency, difficulty breathing. Observations use a respirator muscles, breath lips, skin changes / mucous membranes, such as pale, cyanosis.
Rational: Respiratory increased as a result of pain or as an initial compensation mechanism for damage lung tissue.
2). Lung auscultation.
Rational: consolidation and reduced air flow in the lungs indicates the area involved.
3). Investigate changes in mental status / level of consciousness.
Rational: can show increased hypoxia or complications such as mediastinal shift when accompanied by tachypnea, tachycardia, deviation of the trachea.
4). Maintain patency of the airway by positioning, exploitation, and use of a ventilator.
Rational: airway obstruction affecting ventilation and impairs gas exchange.
5). Change positions frequently, place the patient in a sitting position, or lying down.
Rational: maximize lung expansion and drainage secret.
6). Instruct / aids in deep breathing exercises.
Rational: increase the maximum ventilation and oxygenation and prevent atelectasis.
7). Assess client's response to the activity, the period of rest or restricted activity as tolerated.
Rationale: increased consumption of oxygen demand and stress lead to increased dyspnea and changes in vital signs.
8). Give supplemental oxygen with humidification as indicated.
Rational: maximizing the dosage of oxygen.
9). Monitor blood gas analysis, pulse oximetry. Record levels of Hb.
Rational: PO2 decrease, or increase in PCO2 may indicate the need for ventilatory support. Significant blood loss can lead to a decrease in oxygen-carrying capacity.
