St.

Anthony’s College
San Jose, Antique
Nursing Department
NURSING CARE PLAN
CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Impaired Gas GENERAL: Demonstrate INDEPENDENT:
Exchange related improved ventilation Note respiratory rate, Respirations may be Goals partially met.
to altered oxygen and adequate depth, and ease of increased as a result of
supply oxygenation of tissues respiration. Observe pain or as an initial
(hypoventilation). by ABGs within for use of accessory compensatory
patient’s normal range. muscles, pursed-lip mechanism to
breathing, changes in accommodate for the
skin or mucous loss of lung tissue;
membrane color, however, increased
pallor, cyanosis. work of breathing and
cyanosis may indicate
increasing oxygen
consumption and
energy expenditures
and/or reduced
respiratory reserve.

SPECIFIC: Auscultate lungs for Consolidation and lack

Be free of symptoms of air movement and of air movement on the
respiratory distress. abnormal breath operative side are
sounds. normal in the
pneumonectomy
patient; however, the
lobectomy patient
should demonstrate
normal airflow in
remaining lobes.

Investigate restlessness May indicate increased

and changes in hypoxia or
mentation or level of complications such as a
consciousness. mediastinal shift in
pneumonectomy
patient when
accompanied by
tachypnea, tachycardia,
and tracheal deviation.

Assess patient Increased oxygen

response to activity. consumption demand
Encourage rest periods and stress of surgery
and limit activities to can result in increased
patient tolerance. dyspnea and changes in
vital signs with
activity; however, early
mobilization is desired
to help prevent
pulmonary
complications and to
obtain and maintain
respiratory and
circulatory efficiency.
Adequate rest balanced
with activity can
prevent respiratory
compromise.

Note development of Fever within the first

fever. 24 hr after surgery is
frequently due to
atelectasis.
Temperature elevation
within the 5th to 10th
postoperative day
usually indicates a
wound or systemic.
Maintain patent airway Airway obstruction
by positioning, impedes ventilation,
suctioning, use of impairing gas
airway adjuncts. exchange.

Reposition frequently, Maximizes lung

placing patient in expansion and drainage
sitting positions and of secretions
supine to side
positions.

Avoid positioning Research shows that

patient with a positioning patients
pneumonectomy on following lung surgery
the operative side; with their “good lung
instead, favor the down” maximizes
“good lung down” oxygenation by using
position. gravity to enhance
blood flow to the
healthy lung, thus
creating the best
possible match
between ventilation
and perfusion.

Encourage and assist Promotes maximal

with deep-breathing ventilation and
exercises and pursed- oxygenation and
lip breathing as reduces or prevents
appropriate. atelectasis.

Maintain patency of Drains fluid from

chest drainage system pleural cavity to
for lobectomy, promote re-expansion
segmental or wedge of remaining lung
resection patient. segments.
Note changes in
amount or type of Bloody drainage
chest tube drainage. should decrease in
amount and change to a
more serous
composition as
recovery progresses. A
sudden increase in
amount of bloody
drainage or return to
frank bleeding suggests
thoracic bleeding or
hemothorax; sudden
cessation suggests
blockage of tube,
requiring further
evaluation and
intervention.
Observe presence or
degree of bubbling in Air leaks immediately
water-seal chamber. postoperative are not
uncommon, especially
following lobectomy or
segmental resection;
however, this should
diminish as healing
progresses. Prolonged
or new leaks require
evaluation to identify
problems in patient
versus the drainage
system.
Assist with and
encourage the use of Prevents or reduces
incentive spirometer. atelectasis and
promotes re-expansion
of small airways.
Monitor and graph
ABGs, pulse oximetry Decreasing Pao2 or
readings. Note increasing Paco2 may
hemoglobin (Hb) indicate the need for
levels. ventilatory support.
Significant blood loss
can result in decreased
oxygen-carrying
capacity, reducing
Pao2.

Dependent:
Administer
supplemental oxygen Maximizes available
via nasal cannula, oxygen, especially
partial rebreathing while ventilation is
mask, or high- reduced because of
humidity face mask, as anesthetic, depression,
indicated. or pain, and during
period of compensatory
physiological shift of
circulation to
remaining functional
alveolar units.