West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

CLUSTERED NURSING OUTCOME NURSING

RATIONALE RATIONALE EVALUATION
CUES DIAGNOSIS CRITERIA INTERVENTIONS
Impaired gas Excess or deficit in The patient will be able Assess for signs and Collapse of alveoli
exchange related oxygenation and/or to demonstrate symptoms of atelectasis: increases shunting
to alveolar- carbon dioxide improved ventilation diminished chest (perfusion without
capillary elimination at the and adequate excursion, limited ventilation) resulting in
membrane alveolar-capillary oxygenation of tissues diaphragm excursion, hypoxemia.
changes membrane. by ABGs within client’s bronchial or tubular
normal limits as breath sounds, crackles,
By the process of evidenced by increase tracheal shift to affected
diffusion, the in GCS, RR and BP site.
exchange of within normal range,
oxygen and carbon and absence of pale Monitor vital signs. With initial hypoxia and
dioxide occurs in skin by hypercapnia, BP, heart
the alveolar- rate, and respiratory rate
capillary membrane all increase. As the
area. The hypoxia and/or
relationship hypercapnia becomes
between ventilation severe, BP and heart rate
(air flow) and decrease, and arrhythmias
perfusion (blood may occur. Respiratory
flow) affects the failure may ensue when
efficiency of the the patient is unable to
gas exchange. maintain the rapid
Normally there is a respiratory rate.
balance between
ventilation and Assess skin color for For cyanosis to be
perfusion; however, development of present, 5 grams of
certain conditions cyanosis. hemoglobin must be
can offset this desaturated. Cool, pale
balance, resulting skin may be secondary to
in impaired gas a compensatory
exchange. vasoconstrictive response
to hypoxemia.
Older patients have
a decrease in Maintain oxygen This provides for adequate
pulmonary blood administration device as tissue oxygenation.
flow and diffusion ordered, attempting to
as well as reduced maintain oxygen
ventilation in the saturation at 90% or
dependent regions greater.
of the lung where
perfusion is Position the patient with This may improve exercise
greatest. proper body alignment tolerance by maintaining
for optimal respiratory adequate oxygen levels
excursion (if tolerated, during activity.
head of bed at 45
Source: degrees when supine).
Gulanick/Myers.
(2007). Nursing Routinely check the This would cause the
Care Plans, 6th patient’s position so that abdomen to compress the
edition. he does not slide down diaphragm, which would
in bed. cause respiratory
embarrassment.

Change the patient’s This facilitates secretion

position every two movement and drainage
hours. and decreases atelectasis.

Suction as needed. Suction removes

secretions if the patient is
unable to effectively clear
the airway.