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    Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term: Independent: Independent: Short Term

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    DYNA GISELLE ROMERO
    The patient presented with impaired gas exchange as evidenced by an oxygen saturation of 94% and chest x-ray showing low lung volumes and bilateral atelectasis. Short term goals included gradually improving oxygen saturation through nursing interventions over 8 hours. Long term goals were for the patient to maintain normal oxygen saturation range after 1 week of nursing care, including monitoring vitals, suctioning secretions, and adjusting ventilator settings as ordered. Evaluation showed the goals were met as oxygen saturation improved within normal limits.

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    Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term: Independent: Independent: Short Term

    Uploaded by

    DYNA GISELLE ROMERO
    23 views2 pages
    The patient presented with impaired gas exchange as evidenced by an oxygen saturation of 94% and chest x-ray showing low lung volumes and bilateral atelectasis. Short term goals included gradually improving oxygen saturation through nursing interventions over 8 hours. Long term goals were for the patient to maintain normal oxygen saturation range after 1 week of nursing care, including monitoring vitals, suctioning secretions, and adjusting ventilator settings as ordered. Evaluation showed the goals were met as oxygen saturation improved within normal limits.

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    ncp-1-covid (1)

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    The patient presented with impaired gas exchange as evidenced by an oxygen saturation of 94% and chest x-ray showing low lung volumes and bilateral atelectasis. Short term goals included gradually improving oxygen saturation through nursing interventions over 8 hours. Long term goals were for the patient to maintain normal oxygen saturation range after 1 week of nursing care, including monitoring vitals, suctioning secretions, and adjusting ventilator settings as ordered. Evaluation showed the goals were met as oxygen saturation improved within normal limits.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    23 views2 pages

    Assessment Diagnosis Planning Intervention Rationale Evaluation Short Term: Independent: Independent: Short Term

    Uploaded by

    DYNA GISELLE ROMERO
    The patient presented with impaired gas exchange as evidenced by an oxygen saturation of 94% and chest x-ray showing low lung volumes and bilateral atelectasis. Short term goals included gradually improving oxygen saturation through nursing interventions over 8 hours. Long term goals were for the patient to maintain normal oxygen saturation range after 1 week of nursing care, including monitoring vitals, suctioning secretions, and adjusting ventilator settings as ordered. Evaluation showed the goals were met as oxygen saturation improved within normal limits.

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    © All Rights Reserved
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    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Objectives: Impaired Gas Short term: Independent: Independent: Short term:


    RR: 41 breaths Exchange RT After 8 hours -Assist with -To maintain After 8 hours
    per minute, increase of nursing intubation as ventilator of nursing
    O2 sat: 94% at 4 capillary intervention directed. settings, as intervention
    L/min via nasal membrane patient will ordered, and patient was
    cannula. permeability able to monitor the able to
    (+) diaphoretic as evidenced gradually patient's gradually
    (+) rapid shallow by o2 sat of improve of response. improve of
    breathing. 94% and oxygen - Raise the head - Semi-Fowler’s oxygen
    (+) crackles were chest X-ray saturation of the bed position saturation
    audible showed within promotes a within
    throughout the low lung normal patient’s chest normal
    bilateral lung volumes and range.  expansion. range. 
    fields. bilateral - Monitor oxygen -To create
    Patient was atelectasis Long term: saturation baseline data Long term:
    intubated After a week continuously, and monitor After a week
    Chest X-ray: of nursing using pulse prognosis of nursing
    low lung volumes intervention oximeter. intervention
    and bilateral patient will -Observe the - Discoloration patient was
    atelectasis able to color of the skin of the skin or able to
    maintain and mucous nail beds maintain
    oxygen membrane Peripheral oxygen
    saturation -Monitor cyanosis) may saturation
    within evident further within
    normal reduction of normal
    range. oxygen levels. range.
    - Perform - To remove
    suctioning, as mucous
    needed secretions

    Dependent: Dependent:

    -Administer -For the


    medications as prognosis of the
    ordered. disease
    indicated.

    Collaborative: Collaborative:

    -Refer the chest -For further


    physiotherapist. interventions
    needed.

    https://nursestudy.net/impaired-gas-exchange-nursing-care-plans/

    https://opentextbc.ca/clinicalskills/chapter/5-5-management-of-hypoxemia/
    https://thorax.bmj.com/content/63/Suppl_6/vi1

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