By Shannon O'Dell, CCNS
University of Alabama
Capstone College of Nursing
Tuscaloosa, Alabama

Nursing diagnosis: Impaired gas exchange RT excess mucus production

Goal #1
ABG's WNL pH 7.35-7.45
pO2 80-100
O2 sat 94-100

Nursing Rx
1a. Draw blood to monitor pH qd at 0900.
SR: Arterial blood gas studies aid in assessing the degree to
which the lungs are able to provide adequate oxygen and
remove CO2 and the degree to which the kidneys are able to
reabsorb or excrete bicarbonate ions to maintain normal body
pH. (Smeltzer, 520)
1b. Draw blood to monitor p)2 at 0900 qd.
SR: (see 1a.)
1c. Draw blood to monitor 02 sat at 0900 qd.
SR: (see 1a.)

Goal #2
Vital signs remain WNL. B/P: 90/60 - 140/90
R=12-20/min
P=50-100/min

Nursing Rx
2a. Assess BP q shift (1000, 1800, 0300)
SR: To detect subtle changes. (Sparks, 113)
2b. Assess respirations q shift (1000, 1800, 0300)
SR: To detect tachycardia and tachypnea that could warn of
hypoxemia. (Sparks, 113)
2c. Assess pulse q shift (1000, 1800, 0300)
SR: (See 2b.)

Goal #3
Absence of bronchial secretions.

Nursing Rx
3a. Assess color and consistency of sputum qday.
SR: To facilitate removal of bronchial exudates, changes in
sputum color and thickness are important signs to note.
(Smeltzer, 575)
3b. Administer Albuterol updrafts q4h (0800, 1200).
SR: Inhaled bronchodilators provide direct action on the
airway, thereby improving gas exchange. (Smeltzer, 572)
3c. Administer Humabid LA bid (0800, 2000)
SR: To promote drainage and keep airways clear. (Sparks, 113)

Goal #4
No complaints of bronchospasm.

Nursing Rx
4a. Auscultate for wheezes q shift.
SR: Bronchospasm is detected when wheezes are heard on
auscultation. (Smeltzer, 572)
4b. Assess client for dyspnea q shift.
SR: The relief of bronchospasm is confirmed by measuring
improvement in expiratory flow rate and assessing whether
the client has a reduction in dyspnea. (Smeltzer, 572)
4c. Administer oxygen prn as prescribed.
SR: Increases alveolar oxygen concentration and enhances
arterial blood oxygenation. (Sparks, 114)

Goal #5
No complaints of SOB or DOE.

Nursing Rx
5a. Place client in Fowler's position when awake.
SR: To mobilize secretions and allow aeration of all lung
fields. (Sparks, 113)
5b. Assist client with bathing and dressing.
SR: To decrease tissue oxygen demand. (Sparks, 114)

References

Smeltzer, S.C. & Bave, B.G. (1992). Brunner and Suddarth's
textbook of medical surgical nursing (7th ed.). Philadelphia, PA:
J.P. Lippincott, Co.

Sparks, S.M. & Taylor, C.M. (1993). Nursing diagnosis reference
manual (2nd ed.). Springhouse, PA: Springhouse Corporation.