Cabatingan, Angeli G.

Group 13

Cues/Needs Subjective Data: Mabilis ako mapagod. Kahit pumunta lang ako sa CR pagbalik ko hinihingal na ko.

Nursing Diagnosis Impaired Gas Exchange related to to altered alveolarcapillary membrane changes due to pneumonia disease process.

Objective Data: >Tachypnea RR: 33 breaths per min >Dyspnea >Peripehral Cyanosis

Rationale An infection triggers alveolar inflammation and edema. This produces an area of low ventilation with normal perfusion. Capillaries become engorged with blood, causing stasis. As the alveolocapillary membrane breaks down, alveoli fills with blood and exudates, resulting in atelectasis. Shrunken alveoli cant accomplish gas exchange

Goals and Objectives Long Term Goal: The patient will be able to maintain a normal respiratory rate (20-30 breaths per minute) and breathe without difficulty.

Interventions Independent: >Explain to patient the disease process and management of symptoms

Rationale > To better understand the disease, how it was acquired, how it can be prevented. >To promote lung expansion and decrease respiratory effort. > Early recognition of deterioration in respiratory function will avert further complications.

Evaluation After 8 hours of nursing interventions, the goal was partially met, as evidenced by:  Patient verbalized understanding of causative factors and appropriate interventions  Decreased Respiratory rate from 33 breaths per minute to 29 breaths per minute.

Objectives: After 8 hours of nursing interventions, the patient will be able to:

>Assist the patient in a comfortable position, sitting or semi-fowlers

>Monitor respiratory a. verbalize understanding status, including rate, of causative factors and pattern of appropriate interventions respirations, and breath sounds b. participate in treatment regimen within level of ability > Demonstrate and help the patient perform diaphragmatic and pursed lip breathing.

> Helps patient prolong expiration time and decreases air trapping.

(Source: Lippincott Williams and Wilkins Pathophysiology, p.211)

> Advise the patient to allow the patient to rest and limit activities

> To prevent overexhaustion and reduces oxygen consumption/ demands

Dependent:

> Administer

> Maximizes

supplemental oxygen as indicated

available oxygen, especially while ventilation is reduced >To monitor and prevent potential complications. (Sources:Handbook for Brunner & Suddarths Textbook of Medical Surgical Nursing, 10th Ed. p. 669-670 (Source: Lippincott Williams and Wilkins Pathophysiology, p.215) (Doenges, et. al., Nursing Care Plans, 11th Ed., p. 339-340)

>Administer intravenous fluids and medications and respiratory support as ordered.