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Nursing Care Plan

Date: ________________

Client initials __________Nursing Care PlanLong term goals

Nursing Diagnosis: Ineffective breathing pattern related to decreased lung compliance as evidenced by dyspnea, tachypnea and abnormal ABGs

Client will experience  adequate  perfusion as evidenced by normal arterial blood gas levels* normal for client, decreased tachycardia  & dyspnea

Outcome/Short Term Client Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

Client will have exhibited signs of adequate perfusion.

 

 

 

 

 

Client ABGs will be within normal baseline limits for client.

 

Client will exhibit signs of effective breathing pattern.

 

Client will have adequate tissue perfusion.

 

 

 

 

Monitor pulse oximetry for oxygen saturation and notify for < 90%

 

 

 

 

 

Monitor ABGs for changes and trends.

 

 

Maintain HOB elevation at least 30 degrees.

 

Monitor ECG changes in cardiac rhythm, dysrhythmias, or conduction defects.

Oximetry readings of 90 correlate with PaO2 of 60. Levels below this do not  allow for adequate perfusion to tissues and vital organs. Oximtery uses light waves to identify the differences between the saturation and reduced hemoglobin of the tissues and may be inaccurate in low flow states.

Provides information on acid/base status and oxygenation.
Must consider both oxygenation and ventilation.

 

 

Elevating HOB decreases risk of aspiration and facilitates lung expansion.

Hypoxia can result in life-threatening dysrhythmias that require emergent treatments.

Pulse oximetery readings are > 90%

 

 

 

 

 

 

ABGs remain in normal limits for client.

 

Client will exhibit decreased difficulty breathing.

 

Client will not exhibit dysrhythmias.

 






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