Impaired Gas Exchange
Published on Monday October 12th , 2009
Impaired
Gas Exchange
(_)Actual (_)
Potential
Related
To:
[Check
those that apply]
(_)
Anesthesia
(_) Allergic response
(_) Altered level of consciousness
(_) Anxiety
(_) Aspiration
(_) Decreased lung compliance
(_) Edema of tonsils, adenoids, sinuses
(_) Excessive or thick secretions
(_) Fear
(_) Immobility (_) Improper
positioning |
(_)
Infection
(_) Loss of lung elasticity
(_) Medication
(_) Neuromuscular impairment
(_) Obstruction
(_) Pain
(_) Smoking
(_) Surgery
(_) Other:_____________________________
____________________________________
____________________________________ |
As
evidenced by:
[Check
those that apply]
Major:
(Must be
present) |
(_)
Dyspnea on exertion. |
Minor:
(May be
present) |
(_)
Tendency to assume a three-point position (bending
forward while supporting self by placing one hand on each
knee).
(_) Pursed lip breathing with prolonged expiratory phase.
(_) Increased anteroposterior chest diameter, if chronic.
(_) Lethargy and fatigue.
(_) Increased pulmonary vascular resistance (increased
pulmonary artery/right ventricular pressure).
(_) Decreased oxygen content, decreased oxygen
saturation, increased PCO2.
(_) Cyanosis. |
Date &
Sign. |
Plan and Outcome [Check
those that apply] |
Target
Date: |
Nursing Interventions [Check
those that apply] |
Date
Achieved: |
|
The
patient will:
(_)
Demonstrate optimal gas exchange as permitted by clinical
condition A.E.B.:
- absence of
cyanosis
- ABG’s are within
acceptable limits.
(_) Other:
|
|
(_)
Assess color, respiratory rate and depth, effort, rythm
q___.
(_) Check
for breath sounds q___.
(_) Report ABG’s that
deviate from patient’s baseline.
(_) Position to
facilitate optimum breathing patterns:
- HOB elevated ___
deg.
- turn q____ hrs.
- other:
(_) Cough and deep
breath.
(_) Suction q___ hrs.
(_) Increase actibity
as tolerated to facilitate diaphragm excursion. eg:
________________________
________________________
(_) Encourage fluid
intake to decrease viscosity of secretions (when
indicated).
(_) Explore with
patient potential etiological factors contributing to
impaired gas exchange and provide appropriate health
teaching. (Discharge Plan)
(_)
Other:________________
________________________
________________________
________________________
|
|
__________________________
Patient/Significant other signature
__________________________
RN signature
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