Assess skin color for Development of cyanosis

Topic: Gas Exchange and Assess skin color for development of cyanosis

Provide the expected outcomes for each of the following Nursing interventions:

 

Diagnosis: Risk for aspiration related to Dysphagia

 

Nursing Intervention, rationale and Expected outcome

 

1.Interventions:  Position patient upright during feedings.

Rationale: The elevated head helps keep food in the stomach and reduces aspiration.

Expected outcome:

 

2.Intervention: Assist patient with oral intake

Rationale:  Assisting helps the strategy for safe swallowing.

Expected outcome:

 

3. Intervention: Perform oral care before and after meal.

Rationale: Oral care after eating removes food residues that could cause aspiration at a later time.

Expected outcome:

 

4.Intervention: Patient placed on their side.

Rationale: This position decreases the risk for aspiration by promoting drainage of secretions out of the mouth instead of pharynx.

Expected outcome:

 

 

 

Diagnosis: risk for impaired Gas exchange related to patient’s history of smoking.

 

Nursing intervention/Rationale/Expected out

 

5.Intervention: Position client with head of bed elevated, in a semi-Fowler’s position as tolerated.

Rationale: Semi-Fowler’s position allows increased lung expansion because the abdominal contents are not crowding the lungs.

Expected outcome:

 

6.Intervention: Assess the patient’s nutritional status.

Rationale: Malnutrition can be lead to loss of muscle mass, this can affect breathing muscle.

Expected outcome:

 

7.Intervention: Monitor vital signs.

Rationale: With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise.

Expected outcome:

 

8.Intervention:  Assess skin color for development of cyanosis.

Rationale: To ensure that adequate amount of oxygen is supplied to tissues and organs. 

Expected outcome:

 

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