PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

Intramuros, Manila

COLLEGE OF NURSING

Patient: Cresencia Paras Age: 78y.o Gender: Female Ward: PGH – CenICU
Transferred: September 6, 2010 5:30PM
Admitting Diagnosis: CVD bleed 20cc R Malamic IVE

Nursing Care Plan

Cues Nursing Diagnosis Background Goal and Nursing Evaluation

Knowledge Objectives Interventions and
Rationale

9/13/10 Impaired Gas The causes Short Term Goals / Monitor vital signs. Goal Unmet.
Exchange r/t Outcomes: Rationale: Initially
of cardiovascular
Objectives: altered oxygen with hypoxia and Nursing Care Plan is
• BP – 130/90 supply disease depend on Patient will maintain hypercapnia blood yet to be done.
• 100bpm normal arterial blood pressure (BP), heart
the specific
• 21 cpm gas (ABGs). rate and respiratory
cardiovascular rate all increase. As
• With pulse the condition
oximeter– disease Patient will
becomes more
100% demonstrate a
↓ severe BP may drop,
• With ET tube normal depth, rate
heart rate continues
• GCS – Presence of CVD and pattern of
to be rapid with
E2V1M4 respirations.
arrhythmias and
↓ respiratory failure
Long Term Goal may ensue.
Weak heart

Patient will maintain Assess for changes in

optimal gas exchange orientation and
↓
behavior.
Blood flow and Rationale:
oxygen levels Restlessness is an
early sign of
progressively hypoxia. Mentation
 diminish gets worse as
hypoxia increases
↓
due to lack of blood
Impaired Gas supply to the brain.
Exchage
Place the patient on
continuous pulse
oximetry.
Rationale: Pulse
oximetry is useful in
detecting changes in
oxygenation.
Oxygen saturation
should be maintained
at 90% or greater.

Assess skin color for

development of
cyanosis, especially
circumoral cyanosis.
Rationale: Pulse
oximetry is useful in
detecting changes in
oxygenation.
Oxygen saturation
should be maintained
at 90% or greater.

Position patient with

head of bed 45
degrees (if
tolerated).
Rationale: Promotes
better lung
expansion and
improved gas
exchange.

Suction patient as
needed.
Rationale: Suctioning
aides to remove
secretions from the
airway and optimizes
gas exchange.

Hyperoxygenate
patient with 100%
before and after
suctioning. Keep
suctioning to 10-15
seconds.
Rationale: Prevents
alteration in
oxygenation during
suctioning.

Prepared By:

Kenneth Joy D. Lubiano

Group 5A
BSN IV – I
Ms. R. Simon