After reviewing the information that was gathered, I have come up with these two Nursing Diagnosis:

1. Impaired Gas Exchange r/t ventilation- perfusion imbalance AEB ( havent met pt. yet)
Assess: assess oxygen saturation
Outcome: the patient will demonstrate improved ventilation and adequate oxygenation with oxygen saturation monitoring during PCS.
Intervention: the nurse will keep the patients head of bed elevated to forty five degrees at all times.
Intervention: the nurse will administer oxygen via nasal cannula at four liters per minute to maintain oxygen saturation at ninty percent or higher.

2. Ineffective Peripheral Tissue Perfusion r/t hypertension AEB edema and left foot cool to touch
Assess: assess the patient skin temperature to left foot
Outcome: the patient will demonstrate adequate tissue perfusion by having skin temperature warm to to bilaterral feet during PCS.
Intervention: the nurse will apply antiembolism stockings, as ordered, to patient when out of bed.
Intervention: the nurse will keep the patient warm by applying a blanket.

Narrative Notes after Implementation Phase

Intake: 320ml, compliant with fluid restrictionbeyond what was allowed.
Output: 360ml bright yellow urine.
Alerted nurse on patient apical pulse, respirations, and weight,

Mobility: Patient sitting in semi fowlers position in bed, head of bed to remain elevated at all times with patient. Student explained that she was to move patient to side recliner. Nurse rechecked to make sure bed was low and locked. Nnurse applied antiembolism stockings as ordered when out of bed along with the patients shoes. Student helped patient to grab side rail and turn to side with feet dangling. Patient stated to student, “I get short of breathe so fast”. Student allowed frequent rest periods. Patient denied dizziness or weakness while upright and dangling. With assist times one and walker, student transferred to side chair very slowly. Patient tolerated transfer well. Patient stated, “It feels good to get out of bed”.

Respiratory Assessment: Pt up in bed in semi fowlers position. Student observe patient breathing pattern, respiratory rate 17, regular, and unlaborred. Student explained to patient what the assessment would entail. Student applied stethescope directly on patient skin posteriorly. Patient instructed to breath in and out slowly and deeply. Lung sounds clear to upper lobes posterior bilaterral. Lung sounds to lower right lobe clear and lower left lobe diminished. Patient tolerated assessment without difficulty.

Peripheral Neurovascular Assessment: Patient continues to have edema to bilaterral lower extremities from knee’s down to toes. Patient skin appears with no noticeable abnormalities. Bilateral lower extremities warm to touch except for left foot which is cooler than right foot. Patient has palpable bilaterral pedal pulses, however, the left foot has a more weak pedal pulse compared to the right foot. Capillary refill less than three seconds in toes of both feet. Toes of both feet wiggle simultaneouslywithout difficulty upon command. Patient instructed to close eyes and patient was able to feel sensation on multiple toes of both feet correctly. Patient tolerated assessment well.

Oxygen Management: Patient remains with head of bed elevated to semi fowlers positon. Patient on oxygen at four liters per minute via nasal cannula. No humidification noted. No kinks in the tubing, tubing intact. Skin areas intact around ears, side of face, and nares where nasal cannula is touching. Pt stated, “ the tubing hasn’t bothered me yet”. Patient did have some shortness of breathe with activity of transfer from bed to recliner. Capillary refill less than three seconds on both hands. Student alerted nurse of oxygen saturation at eighty nine percent with oxygen applied at four liters per minute. Patient advised to not keep flammable objects such as electric razor, lighter etc. within four feet of oxygen. Best practice to remove these objects from room with oxygen.

NO REVISION OF CARE PLAN NOTED

Evaluation Phase:

Impaired Gas Exchange r/t ventilation-perfusion imbalance AEB hypoxia
Assess: assess oxygen saturation
Outcome: the patient will demonstrate improved ventilation and adequate oxygenation with oxygen satuaration monitoring during PCS.
Intervention: the nurse will keep the patient head of bed elevated to forty five degees at all times.
Intervention: the nurse will administer oxygen via nasal cannula at four liters per minute to maintain oxygen saturation at ninty percent or greater.
Progress toward achievment: unmet
Patient response that supports patient progress toward outcome: Although the outcome was unmet and the patient oxygen saturation was below ninty percent, continuing these interventions will eventually meet the outcome.

Rationale: According to Maslows heirachy of needs proper ventilatin ia a basic physiological need that must be met in order for for Mr. Julio to acieve homeostasis and sustain life. Without proper ventilation, it may interfere with Mr. Julio ability to perform activities of daily living, progress toward healing, participation in treatment plan and could prolong hospitalization.