Impaired Gas Exchange
Impaired Gas Exchange
(_)Actual (_) Potential
| (_)
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:_____________________________ ____________________________________ ____________________________________ |
| 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.:
(_) 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:
(_) 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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