Impaired Gas Exchange
Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.
Pleural Effusion is an accumulation of fluid in the pleural space. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.
Nursing Diagnosis for Pleural Effusion
Impaired Gas Exchange related to alveolar – capillary membrane changes and respiratory fatigue secondary to Pleural Effusion
Goal :
Patient will verbalize understanding of the interventions given to improve patient’s condition.
Patient will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.
Nursing Interventions and Rational :
Monitor and record vital signs
R/: To obtain baseline data
Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
R/: To note for etiology precipitating factors that can lead to impaired gas exchange
Monitor respiratory rate, depth and rhythm
R/: To assess for rapid or shallow respiration that occur because of hypoxemia and stress
Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation
R/: To determine patients oxygenation status
Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.
Pleural Effusion is an accumulation of fluid in the pleural space. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.
Nursing Diagnosis for Pleural Effusion
Impaired Gas Exchange related to alveolar – capillary membrane changes and respiratory fatigue secondary to Pleural Effusion
Goal :
Patient will verbalize understanding of the interventions given to improve patient’s condition.
Patient will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.
Nursing Interventions and Rational :
Monitor and record vital signs
R/: To obtain baseline data
Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
R/: To note for etiology precipitating factors that can lead to impaired gas exchange
Monitor respiratory rate, depth and rhythm
R/: To assess for rapid or shallow respiration that occur because of hypoxemia and stress
Provide supplemental oxygen at lowest concentration indicated by laboratory results and client symptoms/ situation
R/: To determine patients oxygenation status
