West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Nursing Nursing
Clustered Cues Rationale Outcome Criteria Rationale Evaluation
Diagnosis Interventions
Impaired gas Impaired gas exchange is The client will be Monitor pulmonary Changes in
exchange related to excess or deficit in able to maintain status as directed pulmonary status
lung impairment oxygenation and/or optimal gas and as needed: indicate
and surgery carbon dioxide exchange by proper a. Auscultate improvement or
elimination at the alveoli- positioning, breath sounds. onset of
capillary membrane. breathing exercises, b. Check rate, complications.
hydration, oxygen depth, and
Injuries to the chest are
administration and pattern of
often life-threatening and
bronchodilators as respirations.
result in one or
evidenced by c. Assess blood
more of the following
gases for signs
pathologic mechanisms:
of hypoxemia or
CO2 retention.
Hypoxemia from
d. Evaluate
disruption of the airway;
patient’s color
injury to the
for cyanosis.
lung parenchyma, rib
cage, and respiratory
Monitor and record Aids in evaluating
musculature;
blood pressure, apical effect of surgery on
massive hemorrhage;
pulse, and temperature cardiac status.
collapsed lung; and
every 2–4 hours,
pneumothorax.
central venous
pressure (if indicated)
Ventilation is the flow of
every 2 hours.
gas in and out of the
lungs, and perfusion is
the filling of the
Promote more effective
pulmonary capillaries with
breathing pattern for
blood. better gas exchange:

Adequate gas exchange a. Instruct in a. Upright and

depends on an adequate positioning for semi-fowler’s
ventilation–perfusion optimal positions
ratio. breathing. favor better
lung
In different areas of the expansion;
lung, the ratio varies. the
Alterations in perfusion diaphragm is
may occur with a change pushed
in the pulmonary artery downward. If
pressure, alveolar the patient is
pressure, and gravity. bedridden,
Airway blockages, local turning from
changes in compliance, side to side at
and gravity may alter least 2 hours
ventilation. promotes
A ventilation–perfusion better
V˙/Q˙ imbalance occurs aeration of all
from inadequate lung lobes.
ventilation, inadequate
perfusion, or both. b. Teach and b. This
demonstrate encourages
Ventilation and perfusion pursed-lip more
imbalance causes breathing. complete
shunting of blood, exhalation.
resulting in hypoxia (low
cellular oxygen level). c. Teach NA to use c. This assists in
Shunting abdominal a more
appears to be the main breathing. forceful
cause of hypoxia after exhalation.
thoracic surgery. d. Teach the
therapeutic use d. To protect
A pneumothorax is a of splint when site injury
collection of gas in the coughing and minimize
pain from
pleural space that results
in collapse of the lung/s.
When air enters the
pleural space, pleural
pressure in the affected
hemothorax tends toward
atmospheric pressure;
the less the negative
pressure, the greater the
degree of lung collapse.
It then causes a
mediastinal shift. This
mediastinel shift may
cause compression of the
lung in the direction of
the shift or compression,
traction torsion or kinking
of the great vessels thus
blood return to the heart
is dangerously impaired.
Source:
Harrison’s Principles of
Internal Medicine 11th Ed,
Braunwald Et.al
coughing
Elevate the head of the This facilitates
bed 30-40 degrees ventilation,
when patient is promotes chest
oriented and drainage from the
hemodynamic status is lower chest
stable. tube, and helps
residual air to rise in
the upper portion of
the pleural
space, where it can
be removed through
the upper chest
tube.
Collaborative:
Position the patient It allows a better
with the good lung match
down. of ventilation and
perfusion and
therefore may
actually improve
oxygenation.
These reduce airway
Perform chest resistance, treat
physiotherapy and infection, and
postural drainage after facilitate secretion
administration of removal.
bronchodilator as
indicated.
References:
Nurse’s Pocket Guide
2008 11th Edition by
Doenges et al
Medical-Surgical
Nursing 2004 7th
Edition by Black &
Hawks

Brunner and
Suddarth’s Textbook of
Medical-Surgical
Nursing 2004 10th
Edition by Smeltzer &
Bare

Nursing Care Plans

2007 6th Edition
Gulanalick/Myers