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. / Goals
[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:______
______
______
______