Julia Delcour Nursing Care Plan October 23, 2007
Nursing Diagnosis:
Impaired gas exchange related to fluid overload as manifested by requirements of oxygen supplementation and shortness of breath
with activity.
Expected Outcomes:
Patient will be able to breathe on room air without shortness of breath by discharge.
Nursing Interventions/Rationale:
Encourage deep breathing techniques to open up lung bases increase oxygen exchange in blood. Opening up all the way to the bases
increases surface area for oxygen exchange. (Ackley, B. J., Ladwig, G. B.)
Teach patient the importance of deep breathing. It is important that patient be involved in their return to health and will increase
compliance. (Ackley, B. J., Ladwig, G. B., 2008)
Auscultate breath sounds, listening for sounds of crackles or wheezes. The presence of crackles or wheezes would indicate fluid is
filling his lungs: further exacerbation of fluid overload. (Ackley, B. J., Ladwig, G. B., 2008)
Position in semi-fowler’s position. Research indicates that keep the head of the bed elevated between a 30 – 45 degree angle
increases oxygenation and gas exchange. (Ackley, B. J., Ladwig, G. B., 2008)
Monitor medications with sedative and analgesic effects; try to use a little as possible. Analgesics and meds that cause sedation can
depress the respiratory rate decreasing oxygen intake and CO2 blown out. (Ackley, B. J., Ladwig, G. B., 2008)
Administer a prophylaxis form of antibiotics to reduce chances of developing pneumonia. Ineffective airway clearance and the fluid
build up in the lungs can lead to the development of pneumonia. (Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’brien, P. G.,
Bucher, L., 2007)
Sodium restricted diet. Decreased amounts of sodium will reduce the amount of fluid retention which will help the underlying problem
of fluid overload. (Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’brien, P. G., Bucher, L., 2007)
Administration of diuretic (preferably a loop diuretic because it is the most potent). This will help remove some of the fluid that is
causing the difficulty with breathing. (Dubois, J. R., 2008)
Monitor electrolyte levels to maintain balance. Fluid overload, diuretics, and other meds can create electrolyte imbalances that lead
to further complications. (Ackley, B. J., Ladwig, G. B., 2008)
Teach the use and benefit of the incentive spirometer as an aide to deep breathing. Opening up the lungs all the way to the bases will
encourage increased gas exchange. (Dubois, J. R., 2008)
Monitory oxygen saturation levels. This will show how therapies to improve gas exchange are doing and determine if extra oxygen
supplementation needs to be provided. (Ackley, B. J., Ladwig, G. B., 2008)
Monitor intake and output volumes. Would like to see a negative balance to confirm effectiveness of diurects and other therapies to
reduce fluids. (Ackley, B. J., Ladwig, G. B., 2008)
Weight patient daily. This will show progress of fluid removal and help determine effectiveness of treatments. (Ackley, B. J., Ladwig,
G. B., 2008)
Collaborate with the respiratory team to develop oxygen treatments to help increase gas exchange. Want to have RT help in the effort
to improve oxygenation to improve gas exchange and slowly limit the amount of supplemental oxygen that is adequate for this patient
so that he can achieve his goal of room air. (Protocol of St. Peter’s Hospital in Olympia, Wa, 2007)
Outcome Evaluation:
Patient able to breath on room air without shortness of breath at discharge.