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NCP Rds 2

The patient presented with ineffective breathing patterns related to hypoxia as evidenced by shortness of breath with activity. Objective findings included signs of an underlying condition, hypoxia, hypercapnia requiring medical ventilation, and refractory hypoxemia. The plan was to obtain labs, complete a respiratory assessment, provide supplemental oxygen, facilitate transfer to a higher level of care if needed, and prepare for rapid sequence intubation. The goals were for the patient's oxygen saturation to be 90-100%, respiratory rate to be 12-20 breaths per minute, and for them to demonstrate two breathing techniques within 12 hours.

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Angelokeizer Gavino
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320 views1 page

NCP Rds 2

The patient presented with ineffective breathing patterns related to hypoxia as evidenced by shortness of breath with activity. Objective findings included signs of an underlying condition, hypoxia, hypercapnia requiring medical ventilation, and refractory hypoxemia. The plan was to obtain labs, complete a respiratory assessment, provide supplemental oxygen, facilitate transfer to a higher level of care if needed, and prepare for rapid sequence intubation. The goals were for the patient's oxygen saturation to be 90-100%, respiratory rate to be 12-20 breaths per minute, and for them to demonstrate two breathing techniques within 12 hours.

Uploaded by

Angelokeizer Gavino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

Subjective Data: Ineffective -Pt oxygen After several -Obtain and The patient feel
“I think my baby Breathing saturation will nursing evaluate labs better from time
has shortness in Pattern related be 90-100% interventions, (ABG) to time.
breathing and to hypoxia as throughout the patient will -Complete a full
evidence by
feels weak” hospitalization. feel better and respiratory
shortness of
-Pt respiratory avoid any assessment to
Objective Data: breath with
activity, use of rate will be 12- complications to detect changes
-Signs of 20 breaths per come. or further
accessory
underlying minute decompensation
muscles, O2
condition saturation of throughout as early as
-Hypoxia and 85%, and hospitalization possible, and
hypercapnia abnormal -Pt will notify MD as
requiring medical ABGS. demonstrate indicated
ventilation two breathing -Provides
-Refractory techniques to supplemental
hypoxemia oxygen as
use during
 PaO2/FiO appropriate
dyspneic
2 ratio -Facilitate
episodes within
 Mild <300 transfer to higher
12 hours.
 Moderate level of care if
<200 necessary
-Pt will
 Severe -Prepare for
verbalized two rapid sequence
<100
ways on how to
 Chest X- intubation, if
prevent COPD necessary
ray
exacerbation. -Prevent
–“white
out” Ventilator
.
 Diffuse Associated
bilateral Pneumonia (VAP)
infiltrates -Monitor
hemodynamics
-Advocate for
lung-protective
strategies:low
tidal volumes,
prone
positioning,
special vent
settings
-Manage
secretions

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