ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS NURSING NURSING EVALUATION

COMPETENCIES THEORIES
Subjective: Independent:
Impaired Gas Short term: Faye Abdellah’s Goal not met.
Patient verbalized Exchange related  Note Record (21 typology of
difficulty in to decreased After 7 hours of respiratory Management nursing problems) AEB after 7 hours,
breathing. oxygen carrying nursing rate, depth, the patient still
capacity of the interventions, the and ease of To facilitate the had difficulty
Objective: blood patient will be respirations. maintenance of breathing.
free of respiratory Observe for oxygen to all
 Low RBC (3.2 distress. use of body cells.
10x^12/L R.F.: accessory
4.50-5.90), muscles,
Hemoglobin pursed-lip
(101 g/L breathing, Virginia
R.F.:135-175), changes in Henderson’s14
Hematocrit skin or Components of
(0.31 vol/fr mucous basic Nursing
R.F.: 0.37-0.53) membrane Care
color, pallor,
 Age of 57 cyanosis. Breathe normally.
years old - Respirations
may be
 Smoking increased as a
history of 41 result of pain or as
years an initial
compensatory

|P a g e
 Nasal flaring mechanism to
noted accommodate
for loss of lung
 RR of 26 bpm tissue; however,
increased work of
 O2 saturation breathing and
of 78% cyanosis may
indicate
 Capillary refill increasing
of more than oxygen
2 seconds consumption and
energy
 Pale and dry expenditures
lips noted and/or reduced
respiratory
 Use of reserve.
accessory
muscles when  Auscultate Safe & Quality
breathing lungs for air Nursing Care
movement
 O2 inhalation and
at 5-10 lpm abnormal
via nasal breath
cannula sounds.
turned to face - Consolidation
mask with and lack of air
rebreather movement on
operative side
 Coarse are normal in the

|P a g e
 crackles and pneumonectomy
wheezing patient; however,
noted upon the lobectomy
auscultation patient should
demonstrate
 CXR PA normal airflow in
revealed remaining lobes.
Pulmonary
Edema,  Investigate Safe & Quality
Pulmonary restlessness Nursing Care
Mass with and changes
Adjacent in mental
Lytic state or level
Destruction of of
the adjacent consciousness
ribs, left upper .
chest wall; - May indicate
Bilateral increased
Pneumonia hypoxia or
and Fibrosis, complications
right upper such as
lobe mediastinal shift
in
pneumonectomy
patient when
accompanied by
tachypnea,
tachycardia, and
tracheal

|P a g e
 deviation.

 Assess patient Safe and Quality

response to Nursing Care
activity.
Encourage
rest periods
and limit
activities to
patient
tolerance.
- Increased
oxygen
consumption
demand
and stress of
surgery can result
in increased
dyspnea and
changes in vital
signs with activity;
however, early
mobilization is
desired to help
prevent
pulmonary
complications
and to obtain
and maintain

|P a g e
 respiratory and
circulatory
efficiency.
Adequate rest
balanced with
activity can
prevent
respiratory
compromise.

 Maintain Safe & Quality

patent airway Nursing Care
by
positioning,
suctioning,
use of airway
adjuncts.
- Airway
obstruction
impedes
ventilation,
impairing gas
exchange.

 Reposition Safe and Quality

frequently, Nursing Care
placing
patient in
sitting

|P a g e
 positions
and supine to
side positions.
- Maximizes lung
expansion and
drainage of
secretions.

 Encourage Health Education

and assist with
deep-breathi
ng exercises
and
pursed-lip
breathing as
appropriate.
- Promotes
maximal
ventilation and
oxygenation and
reduces or
prevents
atelectasis.

 Monitor and Record

graph ABGs, Management
pulse oximetry
readings.
Note

|P a g e
 hemoglobin
(Hb) levels.
- Decreasing
Pao2 or
increasing
Paco2 may
indicate need for
ventilatory
support.
Significant blood
loss can result in
decreased
oxygen-carrying
capacity,
reducing Pao2.

Dependent:

 Administer Quality
supplemental Improvement
oxygen via
nasal
cannula,
partial
rebreathing
mask, or
high-humidity
face mask, as

|P a g e
 indicated.
- Maximizes
available
oxygen,
especially while
ventilation is
reduced
because of
anesthetic, depre
ssion, or pain, and
during period of
compensatory
physiological shift
of circulation to
remaining
functional
alveolar units.

 Administer Legal
Doxofylline Responsibility
( Doxoflix )
200mg 1 tab
BID
8AM-6PM
-- By increasing
intracellular level
of cyclic-3’,5’-
adenosine
monophosphate(

|P a g e
 cAMP);
adrenergics by
increasing
production and
phosphodiesteras
e inhibitors by
decreasing
breakdown.

 Administer Legal
NAC Responsibility
(Fluimucil)
600mg/tab
1tab dissolve
in ½ glass of
water Q12H
NAC
(fluimucil)
1amp IV
Q12H 6AM –
6PM
- Reduces the
viscosity of
pulmonary
secretions by
splitting disulfide
linkages between
mucoprotein

|P a g e
 molecular
complexes.

 Administer Legal
Seretide Responsibility
(Diskuss)
20/125 2puff
& gargle
thereafter BID
8AM-6PM
-Selectively
activates beta 2
adrenergic
receptors, which
results in
bronchodilation
and blocks the
release of allergic
mediators from
mast cells in
respiratory tract.

 Administer PAI Legal

with Responsibility
Pulmodial 1
nebule Q6h
12pm-6am
- By blocking
acetylcholine’s

|P a g e
 effects in bronchi
and bronchioles,
it relaxes smooth
muscles and
causes
bronchodilation.

|P a g e