Saturday, September 20, 2014

Impaired Gas Exchange - Asthma Nursing Diagnosis and Interventions

Nursing Care Plan for Asthma

Nursing Diagnosis : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Goal :
Clients are able to :
  • Respiratory Status: Ventilation.
  • Respiratory status : Airway patency.
  • Vital sign status.

Outcomes :
  • Demonstrate effective cough and breath sounds were clean, no cyanosis and dyspnea (able to produce a sputum sample, is able to breathe easy, no pursed lips)
  • Showed a patent airway (the client does not feel suffocated, the rhythm of breath, respiratory frequency in the normal range, no abnormal breath sounds)
  • Vital signs within normal range (blood pressure, pulse, respiration).


NIC :

Airway Management
  • Open the airway , use techniques jaw thrust or chin lift if necessary.
  • Position the patient to maximize ventilation.
  • Identification of the patient's need for installation of an artificial airway.
  • Attach mayo if necessary.
  • Perform chest physiotherapy if necessary.
  • Remove secretions by coughing or suctioning.
  • Auscultation of breath sounds, note the presence of additional noise.
  • Perform suction on orofaringeal airway.
  • Give a humidifier.
  • Set intake to optimize fluid balance.
  • Monitor respiration and O2 status.

Oxygen Therapy
  • Clean the mouth, nose and trachea.
  • Maintain a patent airway.
  • Set oxygenation equipment.
  • Monitor the flow of oxygen.
  • Maintain the position of the patient.
  • Observe for signs of hypoventilation.
  • Monitor the presence of the oxygenation of the patient's anxiety.


Monitoring vital signs
  • Monitor BP , pulse , temperature , and RR .
  • Note the fluctuations in blood pressure .
  • Monitor VS when the patient is lying down , sitting , or standing .
  • Auscultation of blood pressure in both arms and compare .
  • Monitor BP , pulse , RR , before , during , and after activity .
  • Monitor the quality of the pulse .
  • Monitor respiratory rate and rhythm .
  • Monitor lung sounds .
  • Monitor abnormal breathing pattern .
  • Monitor temperature , color , and moisture.
  • Monitor peripheral cyanosis .
  • Monitor the presence of Cushing's triad ( widened pulse pressure , bradycardia , increased systolic ) .
  • Identify the cause of vital sign changes

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