Assessment Diagnosis Planning Intervention Evaluation

Impaired Gas Exchange After 45 minutes of nursing intervention Monitor respiratory and After the 45 minutes of
Subjective: related to airway and alveoli Client will maintain optimal gas heart rate for any nursing intervention the
Di ak makahinga hin tuhay inflammation as evidenced exchange as evidenced by oxygen changes. client was able to maintain
by Hypoxemia saturation of 90% or greater, arterial optimal gas exchange as
blood gasses (ABGs) within the clients Assess for changes in evidenced by oxygen
Objective: usual range, relaxed breathing, respiratory status such saturation of 90% or
baseline heart rate, alert response as cyanosis, pallor, greater, arterial blood
Pale mentation and no further deterioration changes in the level of gasses (ABGs) within the
Lethargic in the level of consciousness. consciousness, labored clients usual range, relaxed
Weak breathing and breathing, baseline heart
Over fatigue tachypnea. rate, alert response
Pain scale of 7 mentation and no further
Monitor transcutaneous deterioration in the level of
carbon dioxide as consciousness.
ordered.

Monitor arterial blood

gasses and oxygen
saturation as indicated

Provide for adequate rest

between activities during
the day, with a minimal
nighttime interruption in
sleep.