Nursing diagnosis: Impaired gas exchange related to ventilation perfusion imbalance as evidenced by oxygen saturation of 90%.
Expected outcome: Patient will demonstrate oxygen saturation greater than 95% within 24 hours.
Nursing diagnosis: Ineffective airway clearance related to retained secretions as evidenced by crackles in the right middle and lower lobes.
Expected outcome: Patient will demonstrate clear breath sounds in bilateral upper and lower lobes within 24 hours.
Nursing diagnosis: Ineffective breathing pattern related to hyperventilation as evidenced by shortness of breath and RR of 28 breaths per minute.
Expected outcome: Patient will demonstrate RR between 12-20 breaths per minute within 24 hours.
Nursing diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by shortness of breath when ambulating.
Expected outcome: Patient will demonstrate no shortness of breath with ambulation within 24 hours.
The patient has been receiving treatment for the past 24 hours, and currently has a respiratory rate of 20 breaths per minute, crackles in the right lower lobe, breath sounds clear in all other lobes, oxygen saturation of 94% on 2 liters of oxygen via nasal cannula, and denied shortness of breath when ambulating to the bathroom an hour ago.
Initial Discussion Post:
- How will the RN update the plan of care?
- Include one intervention to address each of the nursing diagnoses that are still applicable.
- What criteria will be used to determine if the remaining applicable nursing diagnoses have resolved?