Problem no.

2 : Impaired gas exchange related to altered oxygen carrying capacity of the blood as evidenced by decreased level of
hemoglobin

ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVE INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME
S> O Impaired gas Impaired gas Short Term: > Assess patient's > To be able to Short Term:
O > patient exchange related exchange is a state After 8 hours of condition establish a The patient shall be
manifested: to altered oxygen nursing have demonstrated
• Abnormal in which an baseline data
carrying capacity of interventions, the non pharmacologic
ABG gas:
the blood as individual patient will be able management as
• 11/13/19 – experiences an > Maintain > For the
evidenced by to demonstrate non evidenced by deep
metabolic
acidosis
decreased level of excess or deficit in pharmacological adequate input and mobilization of breathing,
• 11/15/19 – hemoglobin oxygenation and/or management as output secretion coughing and
metabolic Carbon dioxide evidenced by the turning exercises.
acidosis doing deep
elimination at the breathing, Long Term:
• 11/14/19 –
respiratory alveolar capillary coughing and > Minimize blood > To limit adverse The patient shall
alkalosis membrane in turning exercises . loss from effects of anemia have demonstrated
• 11/16/19 – Chronic Kidney procedure adequate
respiratory Long Term: oxygenation of
Disease, the ability
alkalosis After 3 days of tissues by ABGs
• 11/24/19 – of the kidney to nursing > Keep > To reduce irritant result within
respiratory produce interventions, the environment effect of dust and patient's normal
alkalosis erythropoietin is patient will be able allergen/pollutant chemicals on limits and absence
• Hemoglobin
also compromised to demonstrate free airways of respiratory
levels are as
follows: making the ability adequate distress.
• Hgb results oxygenation by
of the blood to ABGs result within > Administer > To treat
(123-153)
• 11/13/19 – carry oxygen patient’s normal medication as underlying
102 decreased. limits and indicated condition
• 11/16/19 – 99
• 11/18/19 -
 104
• 11/21/19 – 95 Even though there absence of > Encourage > Promote optimal
• 11/25/19 – will be enough respiratory distress. frequent position expansion of the
112 oxygen coming
• 11/29/19 –
changes and deep lungs and drainage
from the lungs,
110 there is a lesser breathing/coughing of secretion
• Pale carrying capacity of exercises
palpebral oxygen to the blood
conjunctiva
hence there is >Assist with > To improve
• Confusion
• Restlessness inadequate procedures as respiratory
• Irritability distribution of
oxygen in the individually function/oxygen-
• vital signs are
as follows different parts of indicated carrying capacity
• T: 36.8 the body.
• P: 69
• R: 20
• BP: 140/80 > Reinforce need > To decrease
for adequate rest, dyspnea and
Patient may manifest while encouraging improve quality of
• Diaphoresis
activities such as life
• Pallor
• Somnolecnce breathing and
• Visual coughing exercises
disturbance
• Headache
upon
awakening