ASSESSMENT*

DATA BASE sorted

& grouped for
EACH nursing
diagnosis)
Have six of these
Can be either s or o
O
Crackles on lung
fields
O
Skin color pale
O
ph 7.56
O
HCO3 36.4 mEq/L
O
PaO2 56.7 mm Hg
O
SpO2 88%

ANALYSIS*
Statement
3 part NANDA
NURSING
DIAGNOSIS
Analysis: This is a
75 year old female
dx aspiration
pneumonia and with
a tracheostomy.

Impaired gas
exchange r/t
ventilationperfusion imbalance
AEB abnormal
arterial blood gases

PLAN
CLIENT
Short term Goal
Long term Goal

STG: The client

will maintain
normal ABGs
and O2 sats
during shift
LTG: The client
will be weaned
off the vent and
able to maintain
O2 sats above
97% room air
before discharge
from unit.

IMPLEMENTATION
(NURSING ACTIONS, including teaching)
RATIONALE
NUMBER THEM

1. Assess respiratory rate, depth and ease of

respiration. R:Respiration exceeds 30 breaths/min, a
cardiovascular or respiratory alteration exists.
2. Auscultate breath sounds every 1 to 2 hours. R:
Crackles may alert the nurse for airway obstruction.
3. Assess for cyanosis of the skin. R: Central
cyanosis of the tongue and oral mucosa is indicative
of hypoxia.
4. Position the client in a semirecumbent position
with the HOB at 30 to 45 degree angle. R: To
decrease aspiration of gastric, oral and nasal
secretions.
5. Suction tracheobronchial secretions PRN. R:
Retention of secretions leads to hypoxia and promote
infection.
6. Monitor O2 saturation. R: O2 sat less than 90%
indicates oxygenation problems.
7. Teach the client about energy conservation. R:
Alternating rest periods with activity is helpful to
improve respiratory function.
8. Teach the client about identifying and avoiding
situations that exacerbates impairment of gas
exchange. R: Irritants decrease the clients
effectiveness in accessing oxygen during breathing.
9. Teach the client and family to keep temperature
above 68F and to avoid cold weather. R: Cold air
temperatures causes constriction of the blood
vessels, which impairs the clients ability to absorb
oxygen.

EVALUATION of
STG/LTG GOALS
AND EACH
Nursing ACTION
IMPLEMENTATI
ON
CORRELATE
Numbering

1. ABGs, O2
sats WNL.
STG met.
2. LTG unable
to evaluate this
time

RETHINK REPLAN REDO

REWRITE the Implementations and
tell if will keep in POC, Revise it, or
Delete. Tell who will do it.
This is like a shift report.

1. Registered nurse continue to

assess respiratory rate, depth and
ease of respiration.
2. Registered nurse continue to
auscultate breath sounds every 1 to 2
hours.
3. Registered nurse continue to
assess for cyanosis of the skin. 4.
Position the client in a
semirecumbent position with the
HOB at 30 to 45 degree angle.
5. Registered nurse continue to
suction tracheobronchial secretions
PRN.
6. Registered nurse continue to
monitor O2 saturation
7. Registered nurse continue to teach
the client about energy conservation.
8. Registered nurse continue to teach
the client about identifying and
avoiding situations that exacerbates
impairment of gas exchange.
9. Registered nurse continue to teach
the client and family to keep
temperature above 68F and to avoid
cold weather.