NURSING CARE PLAN

Identified Problem: Dyspnea

Nursing Diagnosis: Impaired Gas Exchange r/t removal of lung tissue evidenced by dyspnea

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
 Had a surgery in the
past to remove the
lower lobe (left) of his
lung.
Objective:
 Shortness of breathing
 Productive cough
(green)
 Fever – 380C
 85%, SaO2 (room air)
Short term objectives: Independent Short term:
After 4 hours of  Note respiratory rate, depth, and ease of  Respirations may be increased After 4 hours of comprehensive
comprehensive nursing respiration. Observe for use of accessory as a result of pain or as an nursing intervention, the patient
intervention, the patient will be muscles, pursed-lip breathing, changes in initial compensatory was able to:
able to: skin or mucous membrane color, pallor, mechanism to accommodate
cyanosis. for the loss of lung tissue Goal partially met: demonstrated
1. Demonstrate appropriate  Auscultate lungs for air movement and  Consolidation and lack of air appropriate coping behaviors
coping behaviors abnormal breath sounds. movement on the operative
side are normal in the
pneumonectomy patient
Long term objectives:  Evaluate cough  Indicates possible obstruction
After 8 hours of  Investigate restlessness and changes in  May indicate increased hypoxia Long term:
comprehensive nursing mentation or level of consciousness or complications such as a After 8 hours of comprehensive
intervention, the patient will be mediastinal shift in nursing intervention, the patient
able to: pneumonectomy patient when was able to:
accompanied by tachypnea,
1. Establish a normal, effective tachycardia, and tracheal Goal met:
respiratory pattern as deviation. 1. Established a normal, effective
evidenced by absence of  Review laboratory data such as ABGs  Determines degree of respiratory pattern as evidenced
cyanosis and other oxygenation and carbon dioxide by absence of cyanosis and other
signs/symptoms of hypoxia, retention signs/symptoms of hypoxia, with
with arterial blood gasses  Review drug screens and pulmonary function  Determines vital capacity/tidal arterial blood gasses (ABGs)
(ABGs) within client’s normal studies volume within client’s normal or
or acceptable range acceptable range
 Assess for concomitant pain/discomfort  This may restrict respiratory
2. Verbalize awareness of 2. Verbalized awareness of
effort
causative factors causative factors
 Suction airway as needed  To clear secretions

 Elevate the head of bed and/or have the
client sit up in a chair, as appropriate
 Encourage slower/deeper respirations, use
of pursed-lip technique, and so on
 To promote physiological and
psychological ease of maximal
inspiration
 To assist the client in “taking
control” of the situation

 Monitor pulse oximetry, as indicated  To verify

maintenance/improvement in
O2 saturation
 Note development of fever  Fever within the first 24 hr after
surgery is frequently due to

Patient’s Name / Room No. | 1

 atelectasis. Temperature
elevation within the 5th or 10th
postoperative day usually
indicates a wound or systemic.

 Maintain patent airway by positioning,  Airway obstruction impedes

suctioning, use of airway adjuncts ventilation impairing gas
exchange.
 Administer supplemental oxygen nasal  Maximizes available oxygen,
cannula, partial rebreathing mask, or high- especially while ventilation is
humidity face mask, as indicated. reduced because of anesthetic,
depression, or pain, and during
period of compensatory
physiological shift of circulation
to remaining functional alveolar
Collaboration units.
 Assist with/review results of necessary  To diagnose the
testing presence/severity of lung
diseases
 For management of underlying
 Administer oxygen at lowest concentration pulmonary condition,
indicated and prescribed respiratory respiratory distress, or cyanosis
medications

Patient’s Name / Room No. | 2