Nursing Care Plan for Impaired Oxygenation

Impaired Oxygenation


Assessment

1. Patient Data

• Name:
• Address:
• Age:
• Gender:
• Level of education:

2. Medical history

• Main complaints: cough, chest pain, increased sputum production, hemoptysis, shortness of breath.
• Family history: a family disease, hereditary diseases and allergies.
• Social history: smoking, work, recreation, environmental conditions, factors allergen.
• The state of the environment: a rundown, marshes, big cities, habits: smoking, activity.

Physical Examination

• Cough: is there any pain when coughing, sputum, shortness of coughing.
• Type cough: is productive, non-productive, continuous.
• When did the cough arises: morning or during activity.
• Sputum: color, odor, consistency: thick / liquid, the amount of blood and frothy.
• Dyspnoea (difficulty breathing): when it arises, the tolerance level of the client's activities.
• Hemoptysis: anytime, anything originators.
• Chest pain: when there is pain, whether the rhythm of breathing.
• Wheezing: sound arising from the air passing through a small channel.
• Skin color: peripheral or central cyanosis.
• Facial edema: usually due to an infection and swelling of the sinuses.
• Chest shape: bird chest, since when did it start.
• Musculoskeletal disorders: is there any use of accessory muscles, weakness, muscle pain.
• Clubbing of nail: Abnormalities of the nails.
• Bad breath: spending waste products of metabolism, kind of smelly breath, acetone, urea and alcohol.
• Breathing pattern: (Neunatus: 30 - 60x/menit; Baby: 44x / min; Children: 20 - 25x / min; adult: 15 - 20x / min), tachypnea, hyperventilation, Kussmaul, cheyne stokes, biot.
• Tactile fremitus: to increase the consolidation and decreased in pneumothorax and pleural effusion.

Physical Examination (Head to Toe)

a. Inspection

• Chest examination starts from the posterior thorax, the client in a sitting position.
• Chest observed by comparing one side to the other.
• Actions carried out from the top (apex) to the bottom.
• Inspection of the posterior thorax and condition the skin color, scars, lesions, masses, such as spinal disorders: kyphosis, scoliosis and lordosis.
• Record the number, rhythm, respiratory depth, and symmetry of chest movement.
• Observations respiratory type, such as: nasal breathing or diaphragmatic breathing, and use of accessory muscles of breathing.
• Abnormalities in chest shape: Barrel Chest; Funnel Chest (Pectus excavatum); Pigeon Chest (Pectus carinatum); kyphoscoliosis; Kiposis; Scoliosis.
• Observations symmetry of chest movement. Movement disorders or inadequate chest expansion indicate lung or pleural disease.
• Observation of abnormal retractions intercostal spaces during inspiration, which can indicate airway obstruction.

b. Palpation

• Thoracic palpation to determine abnormalities in the review of inspections such as: mass, lesion, swelling.
• Assess also the softness of the skin, especially if the client complains of pain.
• Vocal premitus: chest wall vibrations generated when speaking.

c. Percussion

• Normal Percussive sound: Resonant (Sonor) à resonate, low tone. Generated in normal lung tissue.; À dullness generated above the heart or lungs; Tympany àmusikal, resulting in over air-filled stomach.
• Abnormal Percussive sound: Hiperresonan à resonated lower than the resonant and raised in the abnormal lung filled with air. Flatness à very dullness and therefore a higher tone. Percussion can be heard on the thigh, where the area is completely unbiased network.

d. Auscultation

• Normal breath sounds: Bronchial; Bronchovesikular; Vesicular.
• Additional breath sounds: wheezing; Ronchi; Pleural friction rub; Crackles.

Nursing Diagnosis

1. Ineffective Airway Clearance related to :

• Airway obstruction due to thick secretions or foreign bodies.
• Abdominal pain or chest pain that reduces the movement of the chest.
• Drugs that suppress the cough reflex and respiratory center.
• Inadequate hydration, the formation of thick secretions that.
• Immobilization.
• Chronic lung disease that makes it easy buildup of secretions.

characterized by : abnormal breath sounds, productive or non-productive cough, cyanosis, shortness of breath, changes in breathing patterns.


2. Ineffective Breathing Pattern related to

• Inadequate lung development due to: immobilization, obesity and pain.
• Neuromuscular disorders such as tetraplegia, head trauma, anesthesia drugs.
• Airway obstruction due to acute infection, allergy that causes bronchial spasm or edema.

characterized by: dyspnoea, increased respiratory frequency, shallow breathing, chest retraction, enlargement of the fingers (clubbing fingger), breathing through the mouth, cyanosis, orthopneu, vomiting, lung expansion is not elastic.


3. Impaired gas exchange related to:

• Reduced blood volume due to hemorrhage, dehydration.
• Keidakseimbangan excess electrolytes such as blood potassium.

characterized by: cardiac arrhythmias, unstable td, tachycardia or bradycardia, cyanosis, weak, jugular venous distention, reduced urine, edema various respiratory problems (orthopneu, dyspnoea, shortness of breath, cough).



Nursing Interventions

1. Maintaining the airway open.

• Installation of an artificial airway.
• Deep breathing and coughing exercises effective.
• Good position: Fowler or semi-Fowler.
• Suctioning.
• Bronchodilators drug delivery.

2. Mobilization of pulmonary secretions

• Hydration.
• Humidification.
• Postural drainage.

3. Retain and maintain lung development.

• Breathing exercises.
• Installation of mechanical ventilation.
• Installation of chest tube drainage or chest.

4. Reducing / correcting hypoxia and hypoxia due to the compensation body.

• Giving O2 via nasal cannula, catheter, simple mask, endotracheal tube.

5. Increasing gas transportation and cardiak output.

• CPR

Evaluation

Done by collecting repeated data after implementation and the data is compared to the destination.