Ncp Impaired Gas Exchange - Needs To Be Criticized

Cues Subjective: “Namumutla at maputi ang mga daliri ng baby ko. Nanghihina din sya” (The face of the baby is pale as well as his fingers)” as verbalized by the mother of the patient. Objective: • • •

Irritability Pallor on face and fingers on both extremities V/S: T – 36.5 ºC P – 129 bpm R – 58 breaths/min

Lab tests: Hb – 68 gm/L HCT – 0.23% RBC – 2.91 x 1012/L

Nursing Diagnosis Impaired Gas Exchange related to low RBC count as evidenced by pallor on the face and fingers, and dyspnea

Objective General: - To facilitate the maintenance of oxygen to all body cells After 1 day of effective nursing interventions the patient will be able to: 1. Display laboratory values within acceptable range

Intervention

Rationale

Independent: ♦

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Monitor vital signs, note for changes in cardiac rhythm

Hypoxia is associated with signs of increased breathing effort

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Recommend quiet atmosphere and bed rest if indicated 

2. Manifest glow on ♦ Recommend the face and return of mother to stimulate the baby to cry color on the fingers once in a while

Administer packed RBCs or exchange

This enhances rest to lower body’s oxygen requirements and reduces strain on the heart and lungs .

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Enhances lung expansion to maximize oxygenation for cellular uptake.

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Low Hb levels reduce the uptake of oxygen at the alveolar capillary membrane and oxygen delivery to tissues

Collaborative: ♦ Monitor Hb levels

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This will serve as indicators of respiratory function and assess the therapy needed by the patient

 Assess patient’s respirations: Rate, rhythm, depth and and breathing effort

Evaluation Evaluation date: June 17, 2009 Goals: Partially met as evidence by: -

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Increase hemoglobin level after blood transfusion Return of pinkish color on both hands and face

transfusions as indicated

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Administer meds as indicated: - Ferlin i ml BID -Folic Acid 5 mg i tab BID -Fortum 270 mg IV q2H NST

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This increases number of oxygen-carrying cells, improve circulation. PRBCs are used because they are less likely to create circulatory overload

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Drug therapy helps to increase haemoglobin levels and promote maximum potential of wellness