NCP

Cues Nursing Analysis Goal Intervention Rationale Evaluation

Diagnosis
Subjective Impaired Gas is At the end INDEPENDENT: On the
cues: gas exchanged of one week following 5
exchange between the of nursing Note respiratory rate, Provides insight days of
“Nahihirapa related to alveoli and intervention depth, use of into the work of nursing
n ako alveolar- the s, the client accessory muscles, breathing and intervention
huminga” as capillary pulmonary will be able pursedlip breathing; adequacy of s, the client
verbalized membran capillaries to areas of alveolar was able to
by the e changes via diffusion. participate pallor/cyanosis, such ventilation. participate
client. as Diffusion of in treatment as peripheral Tachypnea is in treatment
evidenced oxygen and regimen (nailbeds) versus usually present regimen
Objective by carbon within level central (circumoral) or to some degree within level
cues: dyspnea, dioxide of ability or general duskiness. during illness of ability or
hypoxia & occurs situation. (especially with situation as
O2 hypoxemi passively, fever or upper evidenced
saturation: a, according to respiratory by the
88-89% abnormal their infections), but client’s vital
skin color, concentratio if tachypnea is signs were
Respirato and n differences accompanied maintained
ry rate : abnormal across the by use of normal, as
26 breathing alveolar- accessory well as the
of the capillary muscles of oxygen
 Labored client barrier. inspiration (e.g. saturation
breathin These external for 5 days.
g concentratio intercostals),
n differences the client may However, on
 Harsh must be have sixth-
breath maintained insufficient seventh days
sounds by muscle strength of hospital
from ventilation to sustain the stay, the
both (airflow) of work of client was
lungs the alveoli breathing not able to
upon and (Doenges, maintain
ausculta perfusion Moorhouse, & normal vital
tion (blood flow) Murr, 2008). signs from
of the May 24,
 Skin pulmonary Abnormal 2021.
pallor capillaries. breath sounds
Once this are indicative of Vital signs
 Weak balance is numerous (May 24,
pulses altered, it Auscultate breath problems (e.g., 2021):
will result to sounds, note areas of hypoventilation RR – 26CPM
impaired gas decreased/ such as might O2
exchange adventitious breath occur with saturation –
(Wayne G., sounds as well as atelectasis or 89-91%
2017). fremitus. presence of
secretions, Due to
improper comorbiditie
According to endotracheal s like age
the North (ET) tube
(102 years
American placement, old),
Nursing collapsed lung)
prediabetes,
Diagnosis and must be IHD, and
Association evaluated for weakened
(NANDA-I), further immune
this diagnosis intervention system, the
belongs to (Doenges, client’s
the domain Moorhouse, & situation
Elimination Murr, 2008). continued to
and deteriorate
Exchange, and expired
Respiratory Decreased level on May 25,
Function of 2021.
class, and consciousness
the defining can be an Therefore,
characteristic indirect the goal was
s of it Assess level of measurement partially
include: consciousness and of impaired met.
nasal flaring; mentation changes. oxygenation,
headache but it also
upon impairs one’s
awakening; ability to
cyanosis (in protect the
neonates airway,
only); potentially
confusion; further
abnormal adversely
skin color affecting
(e.g., pale, oxygenation
dusky); (Doenges,
diaphoresis; Moorhouse, &
decreased Murr, 2008).
carbon
dioxide;
dyspnea; These are
visual associated with
disturbances; diminished
abnormal oxygenation
arterial (Doenges,
blood gases; Note client reports of Moorhouse, &
hypercapnia; somnolence, Murr, 2008).
hypoxia; restlessness,
hypoxemia; headache on arising.
restlessness; Assess energy level
irritability; and activity tolerance,
abnormal noting reports or
arterial pH; evidence of fatigue, Elevation or
abnormal weakness, and upright position
breathing problems with sleep. facilitates
(e.g., rate, respiratory
rhythm, function by
depth); Elevate head of bed gravity;
somnolence; and position client however, client
and appropriately. in severe
tachycardia. distress will
In acute seek position of
respiratory comfort
infections, (Doenges,
such as Moorhouse, &
pneumonia, Murr, 2008).
the functions
of gas
exchange in
the lungs To clear or
change maintain open
according to airway, when
the stages of client is unable
the disease, to clear
resulting in secretions, or
two Provide airway to improve gas
pulmonary adjuncts and suction, diffusion when
changes: a as indicated. client is
reduced ratio showing
between desaturation of
ventilation oxygen by
and oximetry or
perfusion ABGs.
and a (Doenges,
decrease of Moorhouse, &
the Murr, 2008).
respiratory
membrane's
total surface
area
available. If
impaired gas
exchange is Oxygen can
left leak out around
untreated, it the mask
will be because of poor
detrimental DEPENDENT: fit, and mask
to the can increase
patient and Avoid use of face client’s
may cause mask in elderly agitation
life- emaciated client. (Doenges,
threatening Moorhouse, &
conditions or Murr, 2008).
even, death
(Pascoal,
L.M., et al). Pharmacologica
l agents are
varied, specific
to the client,
but generally
used to prevent
and control
Administer symptoms,
medications as reduce
indicated (e.g., frequency and
inhaled and systemic severity of
glucocorticosteroids, exacerbations,
antibiotics, and improve
bronchodilators, exercise
methylxanthines, tolerance
antitussives/mucolytic (Doenges,
s, vasodilators). Moorhouse, &
Murr, 2008).

To improve
respiratory
function/oxyge
n-carrying
capacity
(Doenges,
COLLABORATIVE: Moorhouse, &
Murr, 2008).
Assist with
procedures as Promotes
individually indicated. optimal chest
expansion,
mobilization of
secretions, and
oxygen
diffusion
Encourage frequent (Doenges,
position changes and Moorhouse, &
deep-breathing and Murr, 2008).
coughing exercises.
Use incentive
spirometer, chest
physiotherapy,
intermittent positive-
pressure breathing, as
indicated.