Interventions And Rationales Example

NURS2466 NursingDiagnosis: Impaired gas exchange related to ventilation-perfusion imbalance secondary to pneumonia definingcharacteristics(asevidenced by): dyspnea, restlessness, lungs with bibasilar crackles, O2 sat 86% Outcome: The client will have adequate gas exchange, O2sat 90%or above, no cyanosis, and remain oriented Interventions and Rationales (italicized)

Evaluation

1. Assess respirations: note quality, rate rhythm, depth, dyspnea on exertion, use of accessory muscles, position. Abnormality indicates respiratory 2. Monitor for changes in vital signs. Hypoxia causes BP, heart rate and respiratory rate to rise and then drop as it becomes more severe.

1. 0800- SOB with exertion, respirations 24, sitting on edge of bed. 1200- respirations 16, less dyspniec.

3. Encourage client to cough and deep breathe. Rids airway of secretions.

3. Occasional productive cough with thick green sputum

4. Auscultate breath sounds for advenitious sounds. May indicate poor gas exhange.

4. 0800- lungs with coarse crackles throughout ; 1200- lungs with crackles in bases

5. Note changes in O2 sat. Indicates the effectiveness o f gas exhange.

5. 0800- O2 sat 86%; 1200- O2 sat 90%

6. Maintain oxygen therapy. Shows the effectiveness of oxygenation.

6. 0800 oxygen at 3 liters; 1200- oxygen at 2 ½liters

7. Adminster respiratory treatments ordered. To prevent or reverse atelectasis.

7. 1100-Nebulizer treatment given- coughed up thick green sputum. Lungs with fine crackles in bases following tx.

2. 0800- BP 108/60 pulse 98; 1200- BP 114/70 pulse 86