Rez Gioz P.

Apego N-40 ASSESSMENT

Patient: Concha Chief Complaint: SOB DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

OBJECTIVE: - concentrated secretions on airway - dyspnea -coughing - generalized weakness - tachypnea -Oxygen saturation: 94%

Impaired gas exchange related to obstruction of upper airway secondary to concentrated secretions.

Within 30 mins. of nursing interventions the client will be able to demonstrate improved
ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters

1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasalflaring, and abnormal breathing patterns.

> Increased respiratory rate,

use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia. > Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia. > Changes in behavior and mental status can be early signs of impaired gas exchange

After 30 mins. of nursing interventions the client was able to demonstrate

improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters

2. Auscultate breath sounds

3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. 4. Monitor oxygen saturation

> An oxygen saturation of

continuously, using pulse oximeter. Note blood gas results as available.

<90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.
>Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious > Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs. > Gravity and hydrostatic

5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes.

6. Position client with head of bed elevated, in a semiFowler's position as tolerated. 7. If client has unilateral lung disease, alternate semi-

Fowler's position with lateral position (with a 10- to 15degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema. 8. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated.

pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation

> Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm The tripid position can be helpful during times of dypnea >clears airway.

9. Suction secretions.