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Nursing Care Plan

Nursing Diagnosis Long Term Goal


Impaired Gas Exchange r/t altered oxygen supply Patient will maintain optimal
gas exchange

Short Term Goals / Outcomes:


Patient will maintain normal arterial blood gas (ABGs).
Patient will be awake and alert.
Patient will demonstrate a normal depth, rate and pattern of respirations.

Interventions Rationale Evaluation

Assess respirations: Rapid, shallow breathing and Patient is free of signs of


quality, rate, hypoventilation affect gas exchange by distress.
pattern, depth and affecting CO2 levels. Flaring of the nostrils, ABGs show PaCO2 between 35-
breathing effort. dyspnea, use of accessory muscles, 45
tachypnea and /or apnea are all signs of Pts respirations are of a normal
severe distress that require immediate rate and depth.
intervention.

Assess for life- Absence of ventilation, asymmetric breath Patient exhibits spontaneous
threatening sounds, dyspnea with accessory muscle use, breathing, no dyspnea, use of
problems. (i.e. resp dullness on chest percussion and gross accessory muscles, resonance
arrest, flail chest, chest wall instability (i.e. flail chest or on percussion and no chest wall
sucking chest sucking chest wound) all require immediate abnormalities.
wound). attention.

Auscultate lung Absence of lung sounds, JVD and / or Patient’s lungs sounds are clear
sounds. Also tracheal deviation could signify a to auscultate throughout all
assess for the Pneumothorax or Hemothorax. lobes.
presence of jugular
vein distention
(JVD) or tracheal
deviation.

Assess for signs of Tachycardia, restlessness, diaphoresis, Patient is free of signs of


hypoxemia. headache, lethargy and confusion are all hypoxia.
signs of hypoxemia.

Monitor vital signs. Initially with hypoxia and hypercapnia blood Patient is normotensive with
pressure (BP), heart rate and respiratory heart rate 60 – 100 bpm and
rate all increase. As the condition becomes respiratory rate 10-20.
more severe BP may drop, heart rate
continues to be rapid with arrhythmias and
respiratory failure may ensue.

Assess for changes Restlessness is an early sign of hypoxia. Patient is awake, alert and
in orientation and Mentation gets worse as hypoxia increases oriented X3.
behavior. due to lack of blood supply to the brain.

Monitor ABGs. Increasing PaCO2 and decreasing PaO2 are ABGs show PaCO2 between 35-
signs of respiratory failure. 45 and PaO2between 80 – 100.

Place the patient Pulse oximetry is useful in detecting SaO2 via pulse oximetry
on continuous changes in oxygenation. Oxygen saturation remains at 90 – 100%.
pulse oximetry. should be maintained at 90% or greater.

Assess skin color Lack of oxygen delivery to the tissues will Patient is free of cyanosis.
for development of result in cyanosis. Cyanosis needs treated
cyanosis, especially immediately as it is a late development in
circumoral hypoxia.
cyanosis.

Provide Early supplemental oxygen is essential in all Patient is receiving 100%


supplemental trauma patients since early mortality is oxygen. SaO2 via pulse
oxygen, via 100% associated with inadequate delivery of oximetry is 90 – 100%.
O2 non-rebreather oxygenated blood to the brain and vital
mask. organs.

Prepare the patient Early intubation and mechanical ventilation Artificial airway is placed and
for intubation. are necessary to maintain adequate maintained without
oxygenation and ventilation, prior to full complications.
decompensation of the patient.

Treat the Treatment needs to focus on the underlying Appropriate injury specific
underlying injuries problem that leads to the respiratory failure. treatment has been started.
with appropriate
interventions.

If rib fractures
exist:
Paradoxical movements accompanied by No paradoxical movements are
1. Assess for dyspnea and pain in the chest wall indicate noted.
paradoxical flail chest. Flail chest is a life-threatening Patient reports pain as <3 on 0-
chest complication of rib fractures that requires 10 scale.
movements. mechanical ventilation and aggressive Bilateral breath sounds present
2. Provide pulmonary care. in all lobes.
adequate Pain relief is essential to enhance coughing
pain and deep breathing.
3. relief. Absence of bilateral breath sounds in the
presence of a flail chest, indicates a
Assess breath pneumo/hemo thorax.
sounds.

If Pneumothorax or
Hemothorax exist:
A chest x-ray confirms the presence of a
1. obtain chest Pneumothorax and / or Hemothorax.
x-ray A chest tube decreases the thoracic Chest tube is placed and
2. prepare for pressure and re-inflates the lung tissue. connected to 20cm wall suction
insertion of with good tidaling and no air
a chest tube A three sided dressing gives the leak or SQ emphysema noted.
accumulated air a way to escape, thereby
If open decreasing thoracic pressure and preventing Three-sided dressing
Pneumothorax a tension Pneumothorax. A chest tube must maintained. No further
exists place a then be inserted. cardiopulmonary
dressing that is decompensation noted in
taped on three patient.
sides for temporary
management.
Position patient Promotes better lung expansion and Patient’s rate and pattern are of
with head of bed improved gas exchange. normal depth and rate at 45
45 degrees (if degree angle.
tolerated).

Assist patient with Promotes alveolar expansion and prevents Patient is able to cough and
coughing and deep alveolar collapse. deep breathe effectively.
breathing Splinting helps reduce pain and optimizes
techniques deep breathing and coughing efforts.
(positioning,
incentive
spirometry,
frequent position
changes, splinting
of the chest).

Suction patient as Suctioning aides to remove secretions from Patient suctioned for moderate
needed. the airway and optimizes gas exchange. amount of thin yellow
secretion. Lung sounds clear
after suctioning.

Hyperoxygenate Prevents alteration in oxygenation during Patient’s SaO2 remained >90%


patient with 100% suctioning. during suctioning.
before and after
suctioning. Keep
suctioning to 10-15
seconds.

Pace activities and Even simple activities, such as bathing, can No changes to cardiopulmonary
provide rest increase oxygen consumption and cause status noted during activity.
periods to prevent fatigue. Patients SaO2 remains >90%
fatigue. during activities.