ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Impaired gas At the end of the shift 1. Monitor the client’s 1. Frequent Partially met.
(Patient is non exchange related to the patient will respiratory rate, monitoring of the At the end of the shift
communicating but ventilation-perfusion demonstrate depth, and effort. client’s respiratory the patient
able to obey simple imbalance as improved ventilation parameters allows for demonstrated
commands. evidenced by cardio- and adequate early identification of improved ventilation
respiratory distress, oxygenation of any changes in and partially
hyperventilation, tissues by arterial breathing patterns or adequate
restlessness, low blood gases (ABGs) effort. oxygenation of
GCS and abnormal within client’s 2. Monitor ABG or 2. An arterial or tissues by arterial
ABG normal range and VBG analysis results. venous blood gas is blood gases (ABGs)
free of symptoms of possibly the most within client’s
respiratory distress. valuable laboratory normal range and
test as it allows for free of symptoms of
the evaluation of pH respiratory distress.
status, serum CO2,
and serum HCO3.
OBJECTIVE DATA: 3. Instruct the client 3. Keeping the client
(on admission) to maintain an in an upright
T: 36.1 C upright position or position or elevating
P: 112 bpm elevate the head of the head of the bed
RR: 35 bpm the bed. promotes optimal
BP: 101/55 mmHg lung expansion and
02 sat: 88-92 % (with ventilation.
oxygen supplement
of 2Lpm nasal 4. Administer 4. Bronchodilators
cannula) improved at bronchodilators as help relax the
97% after suctioning prescribed. airway’s smooth
Pain Scale: 0 (FLACC muscles, dilate the
pain scale) bronchioles, and
GCS: 10/15 improve airflow.
History: LBBB (left 5. Assist in 5. Noninvasive
bundle branch Block) noninvasive ventilation refers to
Ejection Fraction: ventilatory support as techniques that
40% indicated. provide ventilatory
Right lobe haziness support without
on Chest Xray endotracheal
intubation.
ABG result:
pH: 7.5 6. Monitor the 6. Changes in
pCO2: 32 client’s behavior and behavior and mental
pO2: 78 mental status for the status can be early
HCO3: 28 onset of restlessness, signs of impaired gas
(Respiratory agitation, confusion, exchange.
Alkalosis) and (in the late
stages) extreme
lethargy.
+ tachypneic
+ productive cough 7. Monitor oxygen 7. Pulse oximetry is a
+ increased secretions saturation useful tool to detect
+ bilateral harsh continuously, using a changes in
breath sounds pulse oximeter. oxygenation.
+ bibasilar
crepitations 8. Assess the lungs 8. Any irregularity of
for areas of decreased breath sounds may
ventilation and disclose the cause of
auscultate the impaired gas
presence of exchange.
adventitious sounds.
9. Monitor for 9. BP, HR, and
alteration in blood respiratory rate all
pressure (BP) and increase with initial
heart rate (HR). hypoxia and
hypercapnia.

10. Consider the need 10. Early intubation

for intubation and and mechanical
mechanical ventilation are
ventilation. recommended to
prevent full
decompensation of
the client.
Mechanical
ventilation provides
supportive care to
maintain adequate
oxygenation and
ventilation.

11. Suction as 11. Suction clears

necessary. secretions if the
client is not capable
of effectively clearing
the airway.
 ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Risk for Aspiration At the end of the shift 1. Assess level of 1. The primary risk Met.
(Patient is non related to decreased the patient will be consciousness. factor of aspiration is At the end of the shift
communicating but level of free of signs of decreased level of the patient was free
able to obey simple consciousness, aspiration and the consciousness. of signs of aspiration
commands.) inability to swallow/ risk of aspiration is and the risk of
(On Endotracheal dysphagia and decreased. 2. Monitor 2. Increased in aspiration is
tube) presence of respiratory rate, secretions can make decreased.
endotracheal tube. depth, and effort. the risk for aspiration
Note any signs of likely.
aspiration such as
dyspnea, cough,
cyanosis, wheezing,
or fever.
OBJECTIVE DATA: 3. Assess gag reflex 3. The nurse can first
26/9/2023 0800H and ability to safely assess the patient’s
T: 37 C swallow. speech and any
P: 69 bpm difficulty in speaking
RR: 24 bpm which can signal
BP: 127/74 mmHg further issues.
02 sat: 99 % (on
mechanical 4. Assess for presence 4.Nausea or vomiting
ventilator) of nausea or places patients at
Pain Scale: 0 (FLACC vomiting. great risk for
pain scale) aspiration, especially
GCS: 10/15 if the level of
History: LBBB (left consciousness is
bundle branch Block) compromised.
Ejection Fraction: Antiemetics may be
40% required to prevent
aspiration of
Right lobe haziness regurgitated gastric
on Chest Xray contents.

Contraptions: 5.Auscultate lung 5. Adventitious lung

-NGT F12 at right sounds and assess sounds such as
nostril respiratory status. crackles or rhonchi
-Endotracheal tube may be heard with
size 7.5 on aspiration
mechanical ventilator pneumonia. Any
change in respiratory
+ increased secretions status such as an
+ bilateral harsh increased rate, effort,
breath sounds or declining SaO2
+ bibasilar level needs
crepitations immediate attention.
+Poor oral intake and
dysphagia 6. Keep suction 6. Patients at an
machine available at increased risk for
bedside. aspirating should
have functioning
suctioning
equipment at the
bedside for
immediate use.
7. Position properly. 7. Patients with
(on moderate high drooling or
back rest.) uncontrolled
secretions should be
placed side-lying to
allow secretions to
drain and not pool in
their mouths.
 ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Impaired skin At the end of the shift 1. Assess the specific 1. Even clients with Met.
(Patient is not integrity related to the client/caregiver risk factors for existing pressure At the end of the shift
communicating but poor nutritional will receive stage- pressure injuries. injuries continue to the client/caregiver
able to obey simple status, moisture appropriate wound be at risk for further received stage-
commands.) incontinence and care and has injury. Nurses should appropriate wound
immobility as controlled risk consider all potential care and has
evidenced by factors for the risk factors for controlled risk
disruption of the skin prevention of pressure injury factors for the
(multiple community additional ulcers. development. prevention of
acquired pressure additional ulcers.
ulcers).
OBJECTIVE DATA:
(on admission) 2. Determine the 2. Older adult clients
T: 36.1 C client’s age and have less elastic skin,
P: 112 bpm general condition of less moisture, less
RR: 35 bpm the skin. padding, and
BP: 101/55 mmHg thinning of the
02 sat: 80-85 % (with epidermis, making it
oxygen supplement more prone to skin
of Non -Rebreathing impairment.
Mask)
Pain Scale: 0 (FLACC 3. Assess the client’s 3. Malnutrition,
pain scale) nutritional status, hypoproteinemia,
GCS: 10/15 including weight, and anemia reflect
History: LBBB (left weight loss, and the overall status of
bundle branch Block) serum albumin the client and can
Ejection Fraction: levels, if indicated. contribute to tissue
40% vulnerability to
+ Poor oral intake trauma as well as
and dysphagia
 + pressure injuries cause delayed wound
 CAPI- DTI healing.
bilateral heels
 CAPI- unstageable- 4. Assess for a history 4. Clients with
lumbar and Right of preexisting chronic chronic diseases
lateral lower leg diseases typically exhibit
 CAPI- unstageable- multiple risk factors
mixed ulcer with that predispose them
incontinence to pressure injuries.
associated These include poor
dermatitis (IAD) nutrition, poor
-sacral extending to hydration,
perianal area incontinence, and
-Right Scapular immobility.

5. Assess for fecal and 5. The urea in urine

urinary incontinence. turns into ammonia
within minutes and
is erosive to the skin.
While the stool may
contain enzymes that
cause skin
breakdown.

6. Assess and stage 6. Staging is essential

pressure injuries. because it determines
the treatment plan.
Staging should be
assessed at each
dressing stage.
7. Use of pressure- 7. Specialized
relieving devices mattresses and
such as specialized cushions can help
mattresses, cushions, distribute pressure
heel troughs, and more evenly across
other devices the body, reducing
the risk of
developing pressure
injuries.

8. Frequent 8. Repositioning the

repositioning of the client frequently can
client. help to distribute
pressure more evenly
across the body,
decreasing the risk of
developing bed
injuries.

9. Ensure the client 9. Malnutrition is one

eats a well-balanced of the few reversible
diet rich in protein. contributing factors
for pressure injuries,
and establishing
adequate caloric
intake has been
shown to improve the
healing of these
lesions.
 10. Provide local 10. The type and level
wound care as of wound treatment
prescribed. depend on the
staging of the ulcer
and the type of
infection present.

11. Use proper 11. Practicing good

infection control hand hygiene and
measures, such as using personal
hand hygiene and the protective equipment
use of personal can reduce the risk of
protective infection and
equipment, when promote the healing
caring for clients of pressure ulcers.
with pressure ulcers. This can also prevent
further complications
and improve
outcomes for the
client.

1.Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved December 7, 2021, from https://www.cedars-sinai.org/health-
library/diseases-and-conditions/a/aspiration-from-dysphagia.html
2. Carlson-Catalano, J., Lunney, M., Paradiso, C., Bruno, J., Luke, B. K., Martin, T., … & Pachter, S. (1998). Clinical validation of ineffective
breathing pattern, ineffective airway clearance, and impaired gas exchange. Image: the Journal of Nursing Scholarship, 30(3), 243-248.
3. 5 Pressure Injuries (Bedsores) Nursing Care Plans - Nurseslabs