What are nursing care plans? How do you develop a nursing care plan? This care plan is listed to give an example of how a Nurse LPN or RN may plan to treat a patient with those conditions. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The most important part of the care plan is the content, as that is the foundation on which you will base your care. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan. By accessing any content on this site or its related media channels, you agree never to hold us liable for damages, harm, loss, or misinformation.
Pt states she has felt bad since Monday and today is Friday. Pt states she has been coughing up greenish to brownish sputum that is thick. During history collection from pt, pt becomes short of breath and has to stop talking to catch her breath.
On assessment, patients skin feels hot to touch despite the patient stating she feels chilled. Lab and Diagnostic work shows: WBC 30, and chest x-ray preliminary results show possible bilateral lower lobe pneumonia. Complaints of shortness of breath on excretion and atypical chest pain, has felt bad since Monday, states she is coughing up greenish to brownish sputum that is thick, pt feels chilled.Assess 1.
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Ineffective Airway Clearance. Uploaded by rozj Document Information click to expand document information Date uploaded Oct 10, Did you find this document useful? Is this content inappropriate? Report this Document. Flag for inappropriate content. Download Now. Related titles. Carousel Previous Carousel Next. Ineffective airway clearance related to retained mucus secretion as evidenced by unproductive cough. NCP Ineffective airway clearance related to presence of secretion in trachea-bronchial tree secondary to history of CAP.
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Impaired Gas Exchange Care Plan Writing Services
Enlarged prostate,Osteoporosis. Alzheimer's disease, Dementia. Friday, November 26, Impaired Gas Exchange.
Impaired Gas Exchange. Discussion of the Problem. Diffusion is the process by which oxygen and carbon dioxide are exchanged at the air-blood interface. The alveolar capillary membrane is ideal for diffusion because of its thinness and large surface area. In normal healthy adults, oxygen and carbon dioxide travel across the alveolar-capillary membrane without difficulty. Ventilation is the flow of gas in and out of the lungs, and perfusion is the filling of the pulmonary capillaries with blood.
In the healthy lung, a given amount of blood passes an alveolus and is matched with an equal amount of gas A. The ratio is ventilation matches perfusion. Medical conditions that could lead to impaired gas exchange are as follows: COPD, asthma, atelectasis, pulmonary edema, and adult respiratory distress syndrome ARDS heart failure, lung cancer, pneumonia, pulmonary tuberculosis TBrespiratory acidosis, respiratory alkalosis, septicemia, sickle cell crisis, thrombophlebitis, deep vein thrombosis and AIDS.
Other factors affecting gas exchange include high altitudes, hypoventilation, airway blockages, local changes in compliance, gravity, altered oxygen-carrying capacity of the blood from reduced hemoglobin, history of smoking or pulmonary problems, obesity, prolonged periods of immobility, and chest or upper abdominal incisions. In addition, pulmonary blood flow and diffusion decreased as a person ages.
The overall managements for patients with oxygenation problems are to maintain a patent airway, improve comfort and ease of breathing, maintain or improve pulmonary ventilation and oxygenation, improve ability to participate in physical activities, and to prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalances, and feelings of hopelessness and social isolation.
Goal and Objectives. Subjective and Objective Data. Related Factors.
Impaired Gas Exchange – Nursing Diagnosis & Care Plan
Assessment Dx.Forgot your password? Or sign in with one of these services. Hey guys, its that time again Subjective data : The nursing home staff reported the patient was SOB and confused. The patient stated upon admission that he had CHF. He also informed the admissions nurse that he was on oxygen at home. Subjective data: The nursing home staff stated that the client was confused and SOB.
They also stated that he may have aspirated something while eating. The client stated that he was SOB. Objective data : The client is on O 2 in the nursing home. Hx of chronic intermittent hypoxia, asthma, CHF, and pneumonia. The client has bibasilar rales and bilaterial rhonchi. X-ray of the chest shows pulmonary venous congestion that indicates there is pulmonary edema. HR O2 I know it is a really long post but I appreciate the time you are taking out to critique it!
I don't see one of your objective data to support this nursing diagnosis on the list of defining characteristics for the diagnosis. Not one.
Impaired Gas Exchange – Nursing Diagnosis & Care Plan
I'm not saying this patient doesn't have decreased CO-- he probably does-- but to make a nursing diagnosis you must, must identify defining characteristics in your assessment. Extraneous data do not belong in a diagnostic statement.
These outcomes are not related to nursing interventions. Most are results of medical plan of care-- medications, etc. Assessments and monitoring lead to no changes, therefore it is not possible to say that because you do them, goals are met. Anytime you find yourself including " The nursing plan of care should have nursing interventions -- and nursing interventions are, by definition, not merely doing what a physician tells you to do.
And again, assessments do not play any part in change or maintenance of condition, so you cannot attribute met goals to them. Again, "cardiopulmonary dysfunction secondary to a cardiac condition causing the heart to fail" is not an accepted related factor for this diagnosis.
Your objective data include many things that are not defining characteristics for this nursing diagnosis; I encourage you to get your NANDA-I and look at page for the defining characteristics and causes of this diagnosis. If you assessed any of them in this patient, this is the place to note them. Extraneous data are not needed. If there is no problem as you define it it's illogical to say you have met a goal to fix it I see no outcomes on this part anyway.
Also, again, monitoring and following physician plan of care is not evidence of any independent nursing assessment, judgment, or plan. I think you, like many students, are still thinking in terms of medical diagnoses and interventions. You are not using the nursing process to assess your patient and plan his nursing care. It is easy to think that the true statements you put in for rationales have anything to do with what your nursing assessments and plan of care are; they have to do with his condition, but since you don't have defining characteristics for any nursing diagnoses, they don't relate to your plan of nursing care.
You MUST use nursing assessment of defining characteristics for nursing diagnoses, because once you have identified them, the path towards your nursing plan of care as opposed to implementing a medical plan of care will become clear to you. Think like a nurse. Edited Apr 14, by cafeaulait.
Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body. Altered Afterload : Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance PVR ; decreased systemic vascular resistance SVR ; increased pulmonary vascular resistance PVR ; increased systemic vascular resistance SVR ; oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings.Cardiac output is the amount of blood pumped by the heart per minute.
It is the product of the heart rate, which is the number of beats per minute, and the stroke volume, which is amount pumped per beat. Conditions like myocardial infarctionhypertensionvalvular heart disease, congenital heart diseasecardiomyopathy, heart failurepulmonary disease, arrhythmias, drug effects, fluid overload, decrease fluid volume, and electrolyte imbalance are considered the common causes of Decreased Cardiac Output.
The aging process causes reduced compliance of the ventricles, which makes the older population at high risk of developing cardiac problems. In an aging population with steadfast high prevalence of cardiovascular disease CVDthe health care system is handling a growing challenge to efficiently care for these patients. Patients may be managed in an acute care, ambulatory care, or home care setting. The nursing diagnosis Decreased Cardiac Output is characterized by the following signs and symptoms:.
Assessment is required in order to distinguish possible problems that may have lead to Decreased Cardiac Output as well as name any episode that may happen during nursing care. The following are the therapeutic nursing interventions for Decreased Cardiac Output which you can use for writing your nursing care plans NCP :. Since we started inNurseslabs has become one of the most trusted nursing sites helping thousands of aspiring nurses achieve their goals.
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After the usage of this oxygen by the different organs of the body, it will release carbon dioxide as its by-product to be exhaled by the lungs going out from the body. This is the normal gas exchange process of the body. There are times that a person can experience respiratory abnormalities or diseases wherein there is impairment of gas exchange. Impaired gas exchange is the state wherein there is either excess or decrease in the oxygenation of an individual.
There is alteration in the normal respiratory process of an individual. It can have too much oxygen or carbon dioxide in the body which is not very beneficial to the organs or systems.
There are possible causes that may yield to impaired of gas exchange.
Ineffective Airway Clearance
Hypoventilation and low hemoglobin levels can also cause impaired gas exchange. Any diseases related to the respiratory system can cause this alteration in the gas exchange process. It is very important to have a normal respiration because all of the body systems need oxygen in order to function well. Saturday, September 7, Health Conditions.
The best homemade face cream. Care Plans. Share on Facebook. Leave a Reply Cancel reply. Powered by A.Nursing Process Objective and Subjective Data
Jalil ER. It needs immediate intervention. Because too fat or obese patients can have difficulty of breathing because of the increased needs in oxygenation. If the level is low it shows low oxygenation. So it is important to do activities slowly and one at a time. You may administer antibiotics or bronchodilators if prescribed.In addition he became very agitated and distressed when walking to the bathroom according with Moms statement.
Expected Outcomes with Indicators Short Term: The client will demonstrate improved ventilation, adequate oxygenation and will be free of respiratory distress when walking by the end of the shift. Nursing Intervention 1-Monitor respiratory rate, depthand effort, including use of accessory muscles, nasal flaring and abnormal breathing patterns.
Monitor ABGs labs values if available and chest X-rays 4- Position the client in semi-Fowlers position, with an upright posture at 45 degrees if possible.
Scientific Rationale Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the clients eyes may be seen with hypoxia. Ackley,p. It is necessary to continue being monitored this vital sign.
The expiratory wheezing detected earlier wasnt present when examined at the end of the shift. It needs to continue monitoring for a possible return. No consolidation. Long Term: The child and family will implement a daily treatment plan for asthma and reduce the number of asthma episodes, as long as possible and doing so avoiding hospital admissions by 1 month.
Research on healthy subjects demonstrated that sitting upright resulted in higher tidal volumes and minute ventilation versus sitting in a slumped posture. Ackley. The client while on bed was positioned in semi-Fowlers position, and he manifested being comfortable and breathing better in comparison to a lower position on the bed. Provide humidified oxygen through an appropriate device nasal canula or Venturi mask per physician order. The client needed to use oxygen once during shift because his SOB.
When he walks outside of his room he carries his O2 thank. His SOB needs to continue being monitored and continue providing O2 as necessary.
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