NURSING CARE PLAN

Identified Problem: Nursing Diagnosis: Impaired gas exchange r/t alveolar capillary membrane changes and respiratory fatigue secondary to pleural effusion CUES Subjective: OBJECTIVES Short term objectives: -fter . hour of nursing interventions/ the S0O )ill verbali1e understanding of the interventions given to improve patient2s condition0 INTERVENTIONS .0 6stablish rapport0 "0 :onitor and record vital signs0 40 :onitor respiratory rate/ depth and rhythm0 RATIONALE .0 o gain patient2s trust and cooperation0 "0 o obtain baseline data0 40 o assess for rapid or shallo) respiration that occur because of hypoxemia and stress0 ;0 o note for etiology precipitating factors that can lead to impaired gas exchange0 <0 o evaluate degree of compromise0 $0 o enhance lung expansion0 =0 o assess inade5uate systemic oxygenation or hypoxemia0 #0 o promote optimum chest expansion0 ?0 o correct/improve existing deficiencies0 .!0 o determine patient2s oxygenation status0 ..0 o empo)er patient and SO0 ."0 @or the pharmacological management of patient2s condition0 3ong term: he patient shall manifest no signs of respiratory distress0 EVALUATION Short term: he patient shall have verbali1ed understanding of the interventions given to improve patient2s condition0

;0 -ssess patient2s general condition0

<0 -uscultate breath sounds/ note areas of decrease/adventitious breath sounds as )ell as fremitus0 $0 6levate the head of the patient0 =0 Note for presence of cyanosis0 Objective: achypnea pallor !" saturation of #$% Nasal flaring Dyspnea &se of accessory muscle for breathing '/S ta(en are as foll)s: * P* +* ,P* 3ong term objectives: -fter 4 days of nursing interventions/ the pt0 )ill demonstrate improved ventilation and ade5uate oxygenation of tissues -6, minimal dyspnea and improved !" saturation7 !" saturation 8#$%/ near normal or normal !" sat09 #0 6ncourage fre5uent position changes and deep>breathing exercises0 ?0 Provide supplemental oxygen at lo)est concentration indicated by laboratory results and client symptoms/situation0 .!0 +evie) laboratory results0 ..0 Provide health teaching on ho) to alleviate patient2s condition0 ."0 -dministered prescribed medications as ordered0