careplan diagnosis 2

7/30/2019 Careplan Diagnosis 2

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NURS 2564 Fall 2012

High Acuity Client Care Plan

List Nursing Diagnosis: Impaired Gas exchange related to alveolar-capillary membrane changes AEB diminished breath sounds in the

bilateral lower lobes, abnormal ABGs, pleural effusions and pneumonia

General Goal: Patients gas exchange will improve Measured Goal Outcome: Maintain clear upper lung fields and remain free of signs

of respiratory distress

Nursing Interventions Client Response to Interventions

1. Review the patients history INDEPENDENT

2. Assess the patients Lungs INDEPENDENT

3. Check the patients Ventilator settings and documentINDEPENDENT

4. Auscultate breath sounds every 1 to 2 hours. Listenfor diminished breath sounds, crackles, and wheezes

INDEPENDENT

5. Position the client in a semi recumbent position withthe head of the bed at a 30- to 45-degree angle to

decrease the aspiration of gastric, oral, and nasalsecretions INDEPENDENT

6. Work with Respiratory therapy to ensure that thepatient is being suctioned appropriately and that the

setting are correct COLLABERATE

7. Review last set of ABGs INDEPENDENT

Patient had a double lung transplant in 2004 and was admitted with acute

respiratory failure

Patients lungs are clear in upper field but breath sound s are diminished

bilaterally in lower lobes.

FiO2= 50; Tidal Volume = 550; Respiratory rate = 22; Peep = 7 Notingthat the patient is not breathing above the vent.

Breath sounds remained clear in the upper lobes but were diminished

bilaterally in the lower lobes.

The patient was maintained with HOB up at 30% at all times, feeding

were put on hold to move the patient higher in bed, but the patient wasreturned to this position immediately afterward.

Respiratory came several times through the night to suction the patientand clear his airway of excess secretions; during this time the ventilator

were settings were compared with thephysicians orders. Breathing

treatments were also given by respiratory therapy

ABGs were assessed Bicarbonate was 17.8; PCO2 31; pH 7.29; pO2


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8. Monitor patient for changes in skin color, peripheraland circumoral INDEPENDENT

9. Monitor oxygen saturation level INDEPENDENT

10.Measure the endotracheal tube to ensure that it hasnot moved out of place INDEPENDENT

11.Turn patient every two hours INDEPENDENT

87.3; CO2 18. Patient is acidotic

Patients lower extremities were blue/purple in color since initialassessment at the beginning of shift, the skin was cool and dry; unable to

assess the inside of the patient mouth due to the ET tube, but the lipswere pink in color

Oxygen saturation level remained controlled by ventilator at 100%

ET tube was unchanged from previous assessments 7.5mm and 23cm tolip.

The patient was turned/repositioned every two hours or less, the nurse

was very active in ensuring that the patient was in the proper place in the

bed and was turned.

Evaluation Summary of clients progress toward the measured goal outcome (met; partially met; not met): Thepatients gas

exchange had improved since admission the day before and since being intubated. However the patient ABGs improved, he is stillacidotic despite being on a controlled vent. The last set of ABGs was unable to be reviewed by the end of the shift. The patient did

have a double lung transplant in 2004 with rejection, currently had pneumonia, suspected atelectasis and was septic. My goal was notmet. My outcome was met, thepatients lungs remained clear in the upper lobes, but still diminished in the lower lobes, this remained

unchanged. In my opinion I feel like the pulmonologist should have come to evaluate the patient and reevaluated the settings on theventilator. The patient was very sick and I do not feel like the respiratory rate was appropriate for the patie nts ABGs.


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My resources and information came fromAckley: Nursing Diagnosis Handbook, 10th Edition

careplan diagnosis 2

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