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NCP

The patient presented with shortness of breath, irritability, and inability to concentrate due to a pulmonary embolism. The nursing diagnosis was impaired gas exchange related to decreased pulmonary perfusion from an embolism blocking blood flow. Over 8 hours, the nurses frequently monitored respiratory status, administered oxygen, kept the patient in high Fowler's position on bed rest, and gave anticoagulant medications. The goals of improving gas exchange and reducing facial grimace were met, as evidenced by normal arterial blood gases, pulse oximetry, mental status, and respiration rate.

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574 views

NCP

The patient presented with shortness of breath, irritability, and inability to concentrate due to a pulmonary embolism. The nursing diagnosis was impaired gas exchange related to decreased pulmonary perfusion from an embolism blocking blood flow. Over 8 hours, the nurses frequently monitored respiratory status, administered oxygen, kept the patient in high Fowler's position on bed rest, and gave anticoagulant medications. The goals of improving gas exchange and reducing facial grimace were met, as evidenced by normal arterial blood gases, pulse oximetry, mental status, and respiration rate.

Uploaded by

Sunshine Isla
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Cues

Problem/head nursing diagnosis Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus.

Scientific explanation

Nursing objectives Within 8 hours of nursing interventions, the patient will be able to know what the effect of PE is and how to prevent it and will be able to reduce a facial grimace of 8 to at least 4, Patient maintains optimal gas exchange as evidenced by:a. Normal arterial blood gases (ABGs) b. Pulse oximetry results within normal range. c. Usual mental status. d. Normal respiration rate.

Subjective: hirap akong huminga Objectives: -Shortness of breath -irritability -inability to concentrate Facial grimace: 8

Nursing intervention -Frequently assess respiratory status including rate, depth, effort, lung sound and SPO2. -Assess the mental status of the client (changes in orientation and behaviour) -Monitor ABGs and note changes -Position the patient in high fowlers position -Administered oxygen as ordered by doctor -Maintain bed rest -Administer medications (anticoagulants) as prescribed by doctor. Ex. lowmolecular-weight heparin, warfarin

Scientific explanation - Impaired ventilation affects gas exchange and worsens hypoxemia (Tachypnea, dyspnea). SPO2 can be used as a noninvasive method to monitors oxygen saturation. - Restlessness is an early sign of hypoxia. Hypoxemia often causes confusion and agitation. - ABGs used to assess gas exchange of Client -To facilitate maximal lung expansion/ improve ventilation and reduce venous return to the right

Evaluation After 8 hours of nursing interventions, the patient will be able to know what the effect of PE is and how to prevent it and will be able to reduce a facial grimace of 8 to at least 4, Patient maintains optimal gas exchange as evidenced by:a. Normal arterial blood gases (ABGs) b. Pulse oximetry results within normal range. c. Usual mental status. d. Normal respiration rate.

etc

side of the heart. -To improve oxygenation. -Bed rest reduces metabolic demands for oxygen - Anticoagulant therapy is preventive by inhibiting further clot formation

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