changes, or altered blood flow
Possibly evidenced by
Dyspnea with exertion, tachypnea
Changes in mentation, irritability
Desired Outcomes/Evaluation Criteria—Client Will
Electrolyte and Acid-Base Balance
Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by ABGs within client’s acceptable limits
and absence of symptoms of respiratory distress.
Knowledge: Disease Process
Verbalize understanding of causative factors and appropriate interventions.
Participate in treatment regimen within level of ability or situation.
Nursing care plan intervention
1. Monitor respiratory rate, depth, and effort.
Rationale: Alveolar hypoventilation and associated hypoxemia lead to respiratory failure.
2. Auscultate breath sounds.
Rationale: Identifies area(s) of decreased ventilation, such as atelectasis, or airway obstruction and changes as client deteriorates or improves, reflecting effectiveness of treatment and dictating therapy needs.
3. Note declining level of awareness or consciousness.
Rationale: Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and
clear from cerebrospinal fluid (CSF) and brain cells.
4. Monitor heart rate and rhythm.
Rationale: Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine in an attempt
to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances.
5. Note skin color, temperature, and moisture.
Rationale: Diaphoresis, pallor, and cool, clammy skin are late changes associated with severe or advancing hypoxemia.
6. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position.
Rationale: These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus.
7. Restrict use of hypnotic sedatives or tranquilizers.
Rationale: In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop.
8. Discuss cause of chronic condition, when known, and appropriate interventions and self-care activities.
Rationale: Promotes participation in therapeutic regimen and may reduce recurrence of disorder.
9. Assist with identification and treatment of underlying cause.
Rationale: Treatment of disorder is directed at improving alveolar ventilation. Multiple team management, including physicians, pulmonologist and respiratory therapists, or neurologists, may be required to address the underlying condition, such as oversedation, brain trauma, COPD, pulmonary edema, aspiration, and promote correction of the acid-base disorder.
10. Monitor and graph serial ABGs and pulse oximetry readings.
Rationale: Evaluates therapy needs and effectiveness. Note: Pulse oximetry monitoring is used to monitor and show early changes in oxygenation, which can occur before other signs or
symptoms are observed.