Friday, March 30, 2012

Impaired Gas Exchange NANDA NOC NIC

Impaired Gas Exchange NANDA : NOC, NIC

Impaired Gas Exchange Definition: Excess or lack of oxygenation and or removal of carbon dioxide in the alveolar capillary membrane.

Defining characteristics:
  • Impaired vision
  • Reduction in CO2
  • Tachycardia
  • Hypercapnia
  • Fatigue
  • Somnolence
  • Irritability
  • Hypoxia
  • Confusion
  • Dyspnoe
  • Nasal pharyngeal
  • Normal blood gas analyzer
  • Cyanosis
  • Abnormal skin color (white, black)
  • Hypoxemia
  • Hypercarbia
  • Headache when waking
  • Abnormal breathing frequency and depth

Related factors:
  • Ventilation perfusion imbalance
  • Alveolar-capillary membrane changes

NOC:
  • Respiratory Status: Gas exchange
  • Respiratory Status: Ventilation
  • Vital Sign Status

Results Criteria:
  • Demonstrate improved ventilation and adequate oxygenation
  • Maintain cleanliness of the lungs and free of signs of respiratory distress
  • Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
  • Vital signs within normal range

NIC:
1. Airway Management
  • Open the airway, using chin lift technique or jaw thrust if necessary
  • Position the patient to maximize ventilation
  • Identification of patients need the installation of an artificial airway device
  • Replace the mayo if necessary
  • Perform chest physiotherapy if necessary
  • Remove secretions by coughing or suctioning
  • Auscultation of breath sounds, record the presence of additional noise
  • Do the suction on the mayo
  • Give bronchodilators if necessary
  • Give your humidifier
  • Adjust fluid intake to optimize the balance
  • Monitor respiration and oxygen status

2. Respiratory Monitoring
  • Monitor on average, the depth, rhythm and respiratory effort
  • Note the movement of the chest, observe the symmetry, the use of additional muscle, supraclavicular and intercostal muscle retraction
  • Monitor breath sounds, such as snoring
  • Monitor breathing patterns: bradipena, takipenia, Kussmaul, hyperventilation, Cheyne stokes, Biot
  • Note the location of the trachea
  • Diagfragma monitor muscle fatigue (paradoxical movement)
  • Auscultation of breath sounds, noting areas of decreased / no ventilation and additional sound
  • Determine the need for suction by mengauskultasi crakles and ronkhi main airway
  • Auscultation of lung sounds after the action for the results.

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